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The increasing number of examinations and interventional radiological procedures that require the administration of contrast medium (CM) in patients at risk for advanced age and/or comorbidities highlights the problem of CM-induced renal toxicity. A multidisciplinary group consisting of specialists of different disciplines—radiologists, nephrologists and oncologists, members of the respective Italian Scientific Societies—agreed to draw up this position paper, to assist clinicians increasingly facing the challenges posed by CM-related renal dysfunction in their daily clinical practice.The major risk factor for acute renal failure following CM administration (post-CM AKI) is the preexistence of renal failure, particularly when associated with diabetes, heart failure or cancer.In accordance with the recent guidelines ESUR, the present document reaffirms the importance of renal risk assessment through the evaluation of the renal function (eGFR) measured on serum creatinine and defines the renal risk cutoff when the eGFR is The cutoff of renal risk is considered an eGFR Intravenous hydration using either saline or Na bicarbonate solution before and after CM administration represents the most effective preventive measure in patients at risk of post-CM AKI. In the case of urgency, the infusion of 1.4% sodium bicarbonate pre- and post-CM may be more appropriate than the administration of saline.In cancer patients undergoing computed tomography, pre- and post-CM hydration should be performed when the eGFR is In patients with more severe renal risk (i.e., with eGFR In magnetic resonance imaging (MRI) using gadolinium CM, there is a lower risk of AKI than with iodinated CM, particularly if doses 30 ml/min/1.73 m2. Dialysis after MRI is indicated only in patients already undergoing chronic dialysis treatment to reduce the potential risk of systemic nephrogenic fibrosis.

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.

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.

Background and objectives Renin-angiotensin system (RAS) inhibitors reduce cardiovascular morbidity and mortality in patients with CKD. We evaluated the cardioprotective effects of the angiotensin-converting enzyme inhibitor ramipril in patients on maintenance hemodialysis. Design, setting, participants, & measurements In this phase 3, prospective, randomized, open-label, blinded end point, parallel, multicenter trial, we recruited patients on maintenance hemodialysis with hypertension and/or left ventricular hypertrophy from 28 Italian centers. Between July 2009 and February 2014, 140 participants were randomized to ramipril (1.25–10 mg/d) and 129 participants were allocated to non-RAS inhibition therapy, both titrated up to the maximally tolerated dose to achieve predefined target BP values. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included the single components of the primary end point, new-onset or recurrence of atrial fibrillation, hospitalizations for symptomatic fluid overload, thrombosis or stenosis of the arteriovenous fistula, and changes in cardiac mass index. All outcomes were evaluated up to 42 months after randomization. Results At comparable BP control, 23 participants on ramipril (16%) and 24 on non-RAS inhibitor therapy (19%) reached the primary composite end point (hazard ratio, 0.93; 95% confidence interval, 0.52 to 1.64; P=0.80). Ramipril reduced cardiac mass index at 1 year of follow-up (between-group difference in change from baseline: −16.3 g/m2; 95% confidence interval, −29.4 to −3.1), but did not significantly affect the other secondary outcomes. Hypotensive episodes were more frequent in participants allocated to ramipril than controls (41% versus 12%). Twenty participants on ramipril and nine controls developed cancer, including six gastrointestinal malignancies on ramipril (four were fatal), compared with none in controls. Conclusions Ramipril did not reduce the risk of major cardiovascular events in patients on maintenance hemodialysis. Clinical Trial registry name and registration number: ARCADIA, NCT00985322 and European Union Drug Regulating Authorities Clinical Trials Database number 2008–003529–17.

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.

I cateteri venosi centrali o permanenti sono sempre più utilizzati nei nostri Centri dialisi. Una delle problematiche emergenti, legata alla lunga permanenza dei CVC permanenti, è la difficoltà nel rimuoverli, a causa della formazione di tenaci aderenze tra tali dispositivi e la parete vasale. Attualmente per tali complicanze, non esistono linee guida definite. Riteniamo quindi importante condividere le singole esperienze e le procedure utilizzate per la loro rimozione anche per poter definire la reale incidenza del fenomeno, le eventuali complicanze e le migliori strategie da attuare. In questo articolo, descriviamo due casi clinici di difficile rimozione di un CVCp posizionato in vena giugulare interna sin ed i metodi utilizzati per la sua estrazione.

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.

In recent years, several studies have evaluated the differences in survival and residual renal function between patients who underwent two times weekly haemodialysis (HDB) and three times weekly haemodialysis (HDT). In most cases, these studies have taken into account only the patient survival but not the time into treatment or “technique survival”. In our centre we have retrospectively evaluated the incident patients that were treated with HDB for at least three months between 01 January 2013 and 01 November 2015, focusing on the HDB technique survival. During the follow-up, 35 patients started treatment with HDB, while 13 with HDT. On average, patients treated with HDT were younger than HDB patients (60.9±15.9 years vs. 77.8±9.6 years, p=0.01), and body weight was higher in HDT patients (71±8 kg vs. 63±13 kg, p=0.01). HDT patients were more frequently affected by two or more comorbidities (diabetes, peripheral vasculopathy, cardiac disease, chronic obstructive lung disease) than patients treated by HDB. The creatinine clearance (CrCl) evaluated at the beginning of treatment was similar in the two groups (7.48±5 mL/min in HDB vs 5.4±5 mL/min in HDT, p=NS). Urine output at the beginning of the study was higher in the HDB than the HDT group (1,785±480 mL/24 h vs. 530±500 mL/24 h, p=0.001). Results. The mean survival of the HDB was 14.9±1.5 months (ranging from 12 to 17.9 months, median 14±2.4 months). During the follow-up period, 12 patients switched from HDB to HDT due to the presence of signs of fluid overload in ten of them. In these patients the CrCl and the urine output were significantly reduced by the end of the treatment (CrCl was 3.4±1.9 mL/min vs 6.8±2 mL/min, p=0.01; urine output was 995±567 mL/24h vs 1400±400 mL/24h, p = 0.02). No hospital admissions for uremic symptoms (pericarditis, pulmonary oedema, severe hyperkalaemia) were recorded throughout the follow-up period in HDB patients. Conclusions. Our study shows that HDB can be proposed in selected patients for a considerable period. Decrease of urine output and presence of symptoms related to fluid overload are the two main factors leading to the switch to HDT treatment.

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.

In recent years, in the Dialysis departments, the need of a team for the construction and the surveillance of vascular access begins to appear. In this article we describe our experience.

È sempre più frequente l’utilizzo di cateteri posizionati nei vasi venosi centrali per il trattamento emodialitico, la terapia infusiva, la nutrizione parenterale e la chemioterapia. Anche i cardiologi ricorrono sempre più spesso all’impianto di cateteri venosi centrali per l’elettrostimolazione e la cardioversione elettrica. Il risultato è la possibilità di comparsa dell’occlusione di tali vene a causa della presenza di questi dispositivi. Questo articolo descrive il caso clinico di un’ampia trombosi coinvolgente la vena cava superiore e la modalità di posizionamento di un catetere venoso centrale, unica possibilità per poter effettuare un trattamento dialitico nel paziente.

Continuous venovenous hemofiltration (CVVH) is a renal replacement therapy that has been successfully used in patients with severe chronic renal failure to prevent contrast-induced acute kidney injury (CI-AKI). In this study, we present a consecutive experience using a new CVVH protocol that has also been applied to patients with acute coronary syndrome (ACS). CVVH was performed in consecutive patients with estimated glomerular filtration rate30 ml/min/1.73 m(2) (mean ± SD, 21.1 ± 7.3 ml/min/1.73 m(2)) undergoing diagnostic or interventional coronary procedures starting after the angiographic procedures. Iopamidol was used as a contrast agent. In the first 6 patients, iopamidol removal by the CVVH hemofilter and kidney was calculated by measuring iopamidol concentrations in the blood, urine, and ultrafiltrate collected during the 6-hour CVVH session. In the second phase, the protocol was applied to 47 additional patients meeting the inclusion criteria. Six-hour CVVH resulted in iopamidol removal comparable with that of 12-hour diuresis (43 ± 12% vs 42 ± 15% of administered, p = NS). CI-AKI occurred in 7.5% of patients in the whole population and no patients had acute pulmonary edema, need for dialysis, or any major bleeding. In conclusion, in a population including patients with ACS with severe chronic renal failure undergoing coronary angiographic procedures, 6-hour CVVH performed only after contrast medium exposure was able to remove an amount of contrast medium similar to that removed by the kidneys in 12 hours and resulted in a low rate of CI-AKI.

Introduction Acutely decompensated heart failure (HF) in patients with diuretic resistance is often treated with extracorporeal ultrafiltration. Peritoneal ultrafiltration (PUF) has been proposed for the long-term management of severe HF after resolution of the acute episode. The aim of the present study was to evaluate the use of PUF in the treatment of chronic refractory HF in patients without end-stage renal disease. Methods This multicenter (10 nephrology departments throughout Italy) retrospective observational study included patients with severe HF refractory to maximized drug treatment. The patients were proposed for PUF because they had experienced at least 3 hospital admissions in the preceding year for acutely decompensated HF requiring extracorporeal ultrafiltration. Results Of the 48 study patients (39 men, 9 women; mean age 74 ± 9 years), 30 received 1 nocturnal icodextrin exchange, 5 required 2 daily exchanges, and 13 received 2 – 4 sessions per week of automated peritoneal dialysis. During the first year, renal function remained stable (initial: 20.8 ± 10.0 mL/min/1.73 m2; end: 22.0 ± 13.6 mL/min/1.73 m2), while pulmonary artery systolic pressure declined to 40 ± 6.09 mmHg from 45.5 ± 9.18 mmHg ( p = 0.03), with a significant concomitant improvement in New York Heart Association functional status. Hospitalizations decreased to 11 ± 17 days/patient–year from 43 ± 33 days/ patient–year before the start of PUF ( p < 0.001). The incidence of peritonitis was 1 episode in 45 patient–months. Patient survival was 85% at 1 year and 56% at 2 years. Conclusions This study confirms the satisfactory results of using PUF for chronic HF in elderly patients.

The use of temporary or tunneled central venous catheters (CVC) is increasing worldwide in hemodialysis patients, but their numerous and potentially severe complications should be taken into account. Among the possible complications, infections are certainly those with the greater impact on morbidity and mortality. Catheter-related infections can affect the CVC exit site, the subcutaneous tunnel or, in the most severe cases, can induce bacteremia and sepsis (CRBSI, catheter-related blood stream infections). CRBSI prevention is of the utmost importance and can be achieved through educational activities for the dialysis personnel and through the use of specific protocols for CVC insertion and management. Indeed, it has been demonstrated that these measures allow a significant reduction of the number of CRBSI, to less than 1 episode per 1,000 catheter days.

Aneurysms (AN) and pseudoaneurysms are among the complications of vascular access. AN is a focal area of expansion, concentric or eccentric, with the wall consistency the same as all elements of the vessel wall (intima, media and adventitia). Pseudoaneurysm, or false aneurysm, is a blood harvesting without vascular wall, it is characterized by a reactive capsule of connective tissue that delimits it. The K/DOQI guidelines recommend a regular program of monitoring and surveillance of the vascular access. Color-Doppler ultrasound is considered a valuable tool in the preoperative evaluation and in the follow-up. The echo-color-Doppler surveillance plays an important role in diagnosis of aneurysm. It allows monitoring the evolution of the aneurysm, studying vessels walls, thickened because of intimal hyperplasia and to identify the presence of thrombotic material and/or calcification of the wall. Early identification of complications and the adoption of corrective measures will extend the life of the vascular access, with benefit for the patient. Moreover, it will reduce health care costs.

The introduction of vaccination against hepatitis B initially reduced the number of HBV (hepatitis B virus) and HDV (hepatitis delta virus) infections, but the decreasing trend of HDV infection seems to have stopped. The aim of this study was to assess the prevalence of HDV infection in the general population living in the catchment area of Legnano Hospital in northern Italy. Of the 22,758 subjects tested in 2007–2008, the 488 who were HBsAg (hepatitis B surface antigen)-positive [including 107 (21.9%) of non-Italian origin] were subsequently tested for anti-HDV antibodies. Of the 488 subjects who tested positive for HBsAg, 24 (4.9%) were anti-HDV positive, all aged between 30 and 60 years. The difference in prevalence between males (7.1%) and females (1.9%) was statistically significant (p

Over past years, there has been a progressive increase in percutaneous endovascular procedures in patients with chronic renal disease, owing to the high incidence of vascular disease, particularly coronary artery disease, in this population. The use of contrast media may further worsen renal function in such patients, in some cases even accelerating the progression towards end-stage renal failure, and may increase patient morbidity and mortality. In this review, we discuss the role of dialysis in preventing contrast-induced nephropathy as well as present indications to its use in patients already on dialysis treatment undergoing diagnostic or therapeutic procedures with contrast medium injection.

Few data are available regarding the prevalence of burnout among dialysis health care workers. Aims of the present study were to assess and compare burnout levels in a sample of nurses and physicians working in dialysis units, and to investigate their relationships with quality of life, in a cross-sectional observational study.A total of 344 workers from 10 dialysis centres in Northern Italy completed a battery of questionnaires including the Maslach Burnout Inventory, the MOS-36 Item Short Form Health Survey [SF36: physical (PCS) and mental (MCS) component scores] and the 30-item General Health Questionnaire (GHQ30). Data on social and demographic characteristics and working conditions were also collected. General Estimating Equations models were used for the analysis.Overall, burnout scores were lower than the Italian normative sample, with no significant differences between physicians and nurses. However, 30% of nurses had high emotional exhaustion vs 18% of physicians (adjusted OR 2.38, P = 0.003). Emotional exhaustion was also predicted by number of worked hours and months worked in dialysis in the previous 2 years. Depersonalisation was predicted by male gender and bad relationship with coworkers. Having no children and having a permanent hospital position predicted low personal accomplishment. PCS was lower in nurses (50.0 vs 53.3, P0.001), while no significant difference was found for MCS and GHQ30. Lower PCS was associated with emotional exhaustion (P = 0.007) and GHQ305 with depersonalization (P = 0.032).Although burnout is not a general problem in dialysis health care providers, a subgroup of them may be identified, who would benefit from supportive measures to prevent this condition. Nurses appeared more burned-out in the emotional exhaustion scale than physicians.

Aneurysms are a common and often difficult complication seen with arteriovenous vascular access for haemodialysis. The purpose of this narrative review is to define and describe the scale of the problem and suggested therapeutic strategies. A narrative review of the published literature illustrated by individual cases is presented with the aim of summarising the relevant literature. The definitions of aneurysm are inconsistent throughout the literature and therefore systematic review is impossible. They vary from qualitative descriptions to quantitative definitions using absolute size, relative size and also size plus characteristics. The incidence and aetiology are also ill defined but separation into true aneurysms and false, or pseudoaneurysms may be helpful in planning treatment, which may be conservative, surgical or radiological. The lack of useful definitions and classification along with the multitude of management strategies proposed make firm evidence based conclusions difficult to draw. Further robust well designed studies are required to define best practice for this common problem.

Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease (CAD), which remains the most common cause of morbidity and mortality in CKD patients. Although the management of CAD is more challenging in patients with CKD than in the general population, and coupled with concerns about further deterioration of renal function and therapy-related toxic effects, CKD patients and those receiving dialysis have not traditionally been included in randomized trials evaluating either medical or revascularization therapies. Thus, only scant data from small prospective studies or retrospective analyses of controlled trials and registries are available, and to date no optimal treatment approach has been defined for this subgroup of patients. However, they potentially have much to gain from the pharmacological, interventional, and surgical strategies used in the general population. Thus, the objective of this review is to summarize the current evidence regarding the management of CAD in CKD patients, in particular with respect to uncertainties regarding coronary revascularization options, and their risk-benefit relationship in such a high-risk population.

Contrast-induced nephropathy (CIN) is one of the most frequent causes of acute kidney injury in hospitalized patients. Its incidence depends on patient risk factors (chronic kidney disease, diabetes, cardiovascular diseases and older age) and procedure-related factors (high contrast dose, intraarterial administration). Chronic kidney disease, especially if associated with diabetes, is the main risk factor for CIN. Hydration before and after contrast administration is the only preventive therapy that is strongly recommended by guidelines in patients at risk. CIN prevention studies have focused mainly on cardiac patients with a moderate renal risk (GFR 60-40 mL/min) who underwent intraarterial contrast administration. Many clinical trials have evaluated the efficacy of hydration associated with sodium bicarbonate and of N-acetylcysteine (NAC) in CIN prevention. Sodium bicarbonate infusion has shown better efficacy than saline infusion, particularly when short infusion times are needed, such as in emergency procedures. NAC has not shown any clear effect, and some positive study results have not been confirmed in other trials. The discussion is still open on the efficacy of renal replacement therapies for the prevention of CIN in individuals at high renal risk (GFR30 mL/min), in whom CIN could mark the entrance to chronic dialysis.

Aims: The introduction of HBV vaccination in Italy has reduced the incidence and prevalence of HBV infection. However, increasing immigration from countries in which HBV is endemic has led to a wave of new HBsAg-positive subjects and their clinical impact needs evaluation. We compared the serological, clinical and epidemiological data relating to Italian and non-Italian subjects referred to a hospital in Northern Italy. Study Design: We retrospectively analysed the laboratory and clinical records of 488 subjects, including 107 (21.9%) non-Italians, in order to find data concerning clinical diagnoses, possible routes of infection, anti-HCV and anti-HDV antibodies. Results: The differences in gender distribution and mean age between the non-Italian Research Article British Journal of Medicine & Medical Research, 3(1): 1-12, 2013 2 and Italian patients were statistically significant (p

In the management of anemia in patients with chronic kidney disease stage 5 undergoing dialysis (CKD-5D), maintaining hemoglobin (Hb) within the range recommended by the guidelines is challenging.The CARISMA study aim was to evaluate the efficacy, safety and tolerability of a once-monthly continuous erythropoietin receptor activator (CERA) for the treatment of anemia in CKD-5D patients. In this single-arm, multicenter, open-label, phase IIIb study, we screened adult patients from 66 centers in Italy receiving intravenous epoetin alfa or beta or darbepoetin alfa. Eligible patients entered the CERA dose titration phase (DTP), followed by an efficacy evaluation period (EEP) and a long-term safety period (LTSP). Patients were analyzed by intention-to-treat (ITT), per protocol (PP) and safety populations.The rate of patients maintaining Hb within the range 10.0-12.0 g/dL throughout the EEP was 63.22% (220/348), and concentration from baseline to any postbaseline time point. CERA may thus offer a convenient and effective treatment 73.94% (122/165) in the ITT and PP population, respectively, periods in both populations. The rate of patients requiring a dose change was higher during the DTP (69.2%) and the LTSP (73.0%) than during the EEP (54.5%), as expected. CERA treatment was generally well tolerated.Once-monthly CERA administered to CKD-5D patients was associated with negligible changes in mean Hb option for these patients.

The introduction of HBV vaccination in Italy has led to a decline in new HBV infections. Increasing immigration over recent years suggests a change in short-term epidemiology of HBV. The aim of this study was to assess the prevalence of HBV infection in the general population living in the catchment area of Legnano Hospital (Northern Italy). In the period 2007-2008, 22,758 inpatients and outpatients were examined for Hepatitis B surface antigen (HBsAg), of whom 1,654 (7.3%) were of foreign origin. Of the 488 patients who were positive for HBsAg (2.1%), 381 (1.8%) were Italian and 107 (6.5%) were born in other countries. In terms of age, the prevalence of HBsAg was significantly higher among non- Italians in every age group (other than those aged >60 and

Background. Peritoneal dialysis (PD) is associated with a depression of T cell function, as suggested by the impaired production of cytokines by Th cells collected from PD patients. Although treatment biocompatibility could be implicated in this immune dysfunction, it has been poorly investigated, thus far. Therefore, we undertook a study aiming to analyze the effects of different peritoneal dialysis fluids on the Th1/Th2 balance in PD patients. Methods. Twenty three patients on continuous ambulatory peritoneal dialysis (CAPD) were evaluated. Seven patients were on CAPD with icodextrin solution (ICO-PD), seven with glucose and lactate/bicarbonate-buffered solution (LAC/BIC-PD), and nine with glucose and lactate-buffered solution (LAC-PD). The Th1/Th2 balance was eval- uated by measuring IFN- (Th1 subset) and IL-4 (Th2 subset), both in circulating and peritoneum-derived Th lymphocytes unstimulated or stimulated by phytohemoagglutinin (PHA). Moreover inflammatory, nutritional and dialysis-related parameters were recorded. Eight normal subjects comprised the control group (CON). Results. Circulating T cells: IFN- was significantly lower in the LAC-PD group (p

Purpose Infections are a major complication of the use of hemodialysis central venous catheters. In our study we evaluated the efficacy of the hemodialysis central venous catheter protocol management adopted in our center, through a retrospective analysis of all hemodialysis central venous catheters inserted over a period of 6 years. Methods Seventy-three tunneled central venous catheters and 75 temporary central venous catheters were inserted in our center from 2003 to 2008 in 148 patients. Results During the follow-up we observed 30 infective events (16 assessed as bacteremias, 14 subcutaneous tunnel or exit site infections) with a rate of 0.65/1,000 days of central venous catheter implantation. Conclusions Our experience confirms, in a 72-month follow-up, the importance of careful central venous catheter management as a crucial feature in reducing the incidence of infective events in patients with central venous catheters in dialytic treatment.

Contrast-induced nephropathy is one of the major causes of kidney failure in hospitalized patients. Its increased frequency is due to the high number of invasive procedures using contrast media performed for diagnostic or therapeutic purposes in patients with cardiovascular diseases with advanced age and chronic comorbidities such as diabetes and preexisting renal failure. There are two main causes of contrast-induced nephropathy: the direct toxic effect of contrast media on kidney tubules (as shown by morphologic alterations of these cells) and the tissue hypoxia of the renal medulla, secondary to the hemodynamic effects brought about by these agents, consisting in a reduction of vascular resistances. In vulnerable patients, these vasoconstrictor effects are not balanced by an effective vasodilatory reserve and probably by a reduced production of antiapoptotic proteins.

Chronic renal failure is an important risk factor in acute coronary syndromes. Patients with chronic renal failure have a worse in-hospital and long-term outcome than patients with normal renal function. Although chronic renal failure is associated with other risk factors (diabetes, hypertension, high Killip class, peripheral vascular disease), multivariate analysis of several studies has consistently shown that chronic renal failure significantly and independently affects outcome in patients with acute coronary syndrome. Such patients are treated less aggressively than patients with normal renal function: beta-blockers, aspirin and statins are less frequently used in the intensive care unit. Few data are available on the immediate and long-term effects of an aggressive strategy based on early coronary angiography and subsequent revascularization in such patients. Moreover, only few patients with advanced renal disease have been enrolled in trials comparing treatment modalities in acute coronary syndrome. However, when great care is taken to avoid high contrast medium load, blood loss and periprocedural hypotension, which may result in deterioration of renal function, interventional techniques may prove to be successful in improving outcome.