Search

Background The known risks and benefits of native kidney biopsies are mainly based on the findings of retrospective studies. The aim of this multicentre prospective study was to evaluate the safety of percutaneous renal biopsies and quantify biopsy-related complication rates in Italy. Methods The study examined the results of native kidney biopsies performed in 54 Italian nephrology centres between 2012 and 2020. The primary outcome was the rate of major complications 1 day after the procedure, or for longer if it was necessary to evaluate the evolution of a complication. Centre and patient risk predictors were analysed using multivariate logistic regression. Results Analysis of 5304 biopsies of patients with a median age of 53.2 years revealed 400 major complication events in 273 patients (5.1%): the most frequent was a ≥2 g/dL decrease in haemoglobin levels (2.2%), followed by macrohaematuria (1.2%), blood transfusion (1.1%), gross haematoma (0.9%), artero-venous fistula (0.7%), invasive intervention (0.5%), pain (0.5%), symptomatic hypotension (0.3%), a rapid increase in serum creatinine levels (0.1%) and death (0.02%). The risk factors for major complications were higher plasma creatinine levels [odds ratio (OR) 1.12 for each mg/dL increase, 95% confidence interval (95% CI) 1.08–1.17], liver disease (OR 2.27, 95% CI 1.21–4.25) and a higher number of needle passes (OR for each pass 1.22, 95% CI 1.07–1.39), whereas higher proteinuria levels (OR for each g/day increase 0.95, 95% CI 0.92–0.99) were protective. Conclusions This is the first multicentre prospective study showing that percutaneous native kidney biopsies are associated with a 5% risk of a major post-biopsy complication. Predictors of increased risk include higher plasma creatinine levels, liver disease and a higher number of needle passes.

The aim of this study was to evaluate urinary potassium (K) excretion as a reliable marker of dietary K intake, in a cohort of CKD patients with or without Renin-Angiotensin-Aldosterone System (RAAS) inhibitor therapy. One hundred and thirty-eight consecutive out-patients (51 f and 87 m) aged 60 ± 13 years and affected by CKD stage 3–4, who were metabolically and nutritionally stable, entered the study between November 2021 and October 2022. No difference was observed between patients with (n = 85) or without (n = 53) RAAS inhibitor therapy, regarding dietary intakes, blood biochemistry, and 24-h urine excretion parameters. Considering all patients, urinary K showed a weak relationship with eGFR (r = 0.243, p < 0.01), and with dietary K intake (r = 0.184, p < 0.05). Serum K was not associated with dietary K intake, but an inverse relationship was observed with eGFR (r = −0.269, p < 0.01). When patients were examined depending on whether they were receiving RAAS inhibitor therapy, the weak inverse relationship between serum K and eGFR was maintained in both groups. Conversely, urinary K excretion remained positively associated with dietary K intake only in the no RAAS inhibitor group. In conclusion, 24-h urine K excretion may be used as a surrogate of K intake, but RAAS inhibitor therapy reduces the association between 24-h urine K excretion and dietary K intake in CKD patients.

Background: Mitochondrial tRNA (MTT) genes are hotspot for mitochondrial DNA mutation and are responsible of half mitochondrial disease. MTT mutations are associated with a broad spectrum of phenotype often with complex multisystem involvement and complex genotype-phenotype correlations. MT-TL1 mutations, among which the m.3243A>G mutation is the most frequent, are associated with myopathy, maternal inherited diabetes and deafness, MELAS, cardiomyopathy, and focal segmental glomerulosclerosis. Case study: Here we report the case of an Italian 49-years old female presenting with encephalomyopathy, chronic proteinuric kidney disease and a new heteroplasmic m.3274_3275delAC MT-TL1 gene mutation. Conclusions: Our case demonstrates a systemic mitochondrial disease caused by the heteroplasmic m.3274_3275delAC MT-TL1 gene mutation, not yet described in the literature. A mitochondrial disease should be suspected in case of complex multisystem phenotypes, including steroid-resistant nephrotic syndrome with multisystemic involvement.

Chronic kidney disease (CKD) represents a frequent comorbidity in cancer patients, especially for patients affected by urological cancers. Unfortunately, impaired kidney function may limit the choice of adequate oncological treatments for their potential nephrotoxicity or due to contraindications in case of a low glomerular filtration rate. For these patients, tailored nephrological and nutritional management is mandatory. The K-DIGO guidelines do not define whether the nutritional management of CKD could be useful also in CKD patients affected by urological cancer. In fact, in clinical practice, oncological patients often receive high-protein diets to avoid malnutrition. In our study, we investigated the nutritional and nephrological impact of a Mediterranean-like diet with a controlled protein intake (MCPD) on a cohort of 82 stage III-IV CKD patients. We compared two cohorts: one of 31 non-oncological CKD patients and the other of 51 oncological patients with CKD. The use of an MCPD had a favorable impact on both the oncological and non-oncological CKD patients with an amelioration in all the investigated parameters and with a better quality of life, with no cases of malnutrition or AKI.

Background Dry weight assessment in hemodialysis (HD) remains a challenge. The aim of the study was to investigate the prevalence of subclinical pulmonary congestion using lung ultrasound (LUS) in maintenance HD patients with no clinical or bioimpedance signs of hyperhydration. The correlation between B-lines Score (BLS) and brain natriuretic peptide (BNP) was also evaluated. Methods Twenty-four HD patients underwent LUS and BNP dosage at the end of the mid-week HD session, monthly for 6 months . LUS was considered as positive when BLS was >15. Hospitalizations and cardiovascular events were also evaluated in relation to the BLS. Results LUS+ patients at baseline were 16 (67%), whereas 11 (46%) showed LUS + in at least 50% of the measurements (rLUS+ patients). Only the rLUS+ patients had a higher number of cardiovascular events [p=0.019, OR: 7.4 (CI 95%. 1.32-39.8)] and hospitalizations [p=0.034, OR 5.5 (CI 95% 1.22- 24.89)]. A BNP level of 165 pg/ml was identified as cut-off value for predicting pulmonary congestion, defined by BLS >15. Conclusion Prevalence of pulmonary congestion as assessed by LUS and persistent or recurrent BLS >15 were quite prevalent findings in euvolemic HD patients. In the patients defined as rLUS+, a higher rate of cardiovascular events and hospital admissions was registered. BNP serum levels > 165 pg/ml resulted predictive of pulmonary congestion at LUS. In the dialysis care, regular LUS examination should be reasonably included among the methods useful to detect subclinical lung congestion and to adjust patients’ dry weight.

Background: The aim of this study was to investigate the long-term effects of ureteral stenting and the exact timing of stent removal in favor of surgery in patients with idiopathic retroperitoneal fibrosis (IRF). Summary: Medline research terms of “idiopathic retroperitoneal fibrosis” AND “ medical therapy” OR “ureteral stenting” OR “surgical treatment” were done. Systematic reviews and observational and clinical studies were analyzed to obtain indication regarding the objective of the study for a narrative review. Ninety-two papers were analyzed. The treatment of IRF includes the monitoring of retroperitoneal fibrotic process spread and the prevention of abdominal organs entrapment. Treatment of ureteral obstruction includes medical therapy and ureteral stenting (US) or percutaneous nephrostomy (PNS) to overcome the worsening of renal function. Up to now, the timing of US or PNS removal is not yet clear, both for the complexity of evaluating the efficacy of the medical therapy and demonstrating the resolution of obstructive nephropathy. Moreover, it is not yet clear if the long-term ureteral stent placement or PNS is able to maintain an efficient renal function. Ureterolysis with a laparoscopic robot-assisted approach is now considered as an ultimate treatment for ureteral obstruction, limiting the progression of kidney impairment and improving the quality of life of patients, although nephrologists are generally abdicant regarding the potential switch toward the surgical approach. Key Messages: Prospective studies regarding the long-term effects of US on the renal function impairment in patients with IRF should be structured to obtain adequate information on the exact timing for the surgical approach.

Patients with urolithiasis, and particularly those with hypercalciuria, frequently have a marked reduction of bone mineral content up to the levels of osteoporosis, with a significant increase in bone fracture risk. For these reasons, the indication to prescribe vitamin D and/or calcium supplementations is very frequent in such patients. On the other hand, both calcium supplementation, and even more vitamin D therapy, can worsen the risk of developing urolithiasis by increasing calcium, phosphate, and oxalate urinary excretion. Despite the clinical and practical relevance of this issue, the evidence on this topic is scarce and contradictory. Therefore, some concerns exist about how and whether to prescribe such supplements to a patient with a history of kidney stones. In this narrative review, we resume some pivotal pathophysiological concepts strictly related to the dealt topic, and we draw some considerations and personal opinions on the pros and cons of such prescriptions. Finally, we share with the reader our pragmatic algorithm for handling the urolithiasis risk in patients who have strong indications to be prescribed vitamin D and calcium supplementations.

A number of studies in the general population showed that healthy dietary patterns, such as the Mediterranean Diet, can improve or prevent the development of several chronic diseases and are associated with a significant reduction in all-cause and cardiovascular mortality. The Mediterranean diet may also have favorable effects for the prevention of chronic kidney disease (CKD), but no evidence of renoprotection exists in CKD patients. The Mediterranean Renal (MedRen) diet is an adaptation of the Mediterranean diet recommendations comprising a quantitative reduction in the RDA values of protein, salt and phosphate intake for the general population. Hence, MedRen supplies 0.8 g/Kg of protein, 6 g of salt and less than 800 mg of phosphate daily. Obviously, there is a preference for products of plant origin, which contain more alkali, fibers, unsaturated fatty acids than animal-based food. The MedRen diet can be implemented easily in mild-to-moderate stages of CKD with good results, both in terms of adherence to prescriptions and metabolic compensation. In our opinion, it should be the first step of CKD stage 3 nutritional management. This paper describes the features and reports our experience in the implementation of the MedRen diet as an early nutritional approach to CKD.

Complementary and alternative medicine (CAM) is often implemented in kidney stone patients. It consists of preparations including different ingredients, such as herbs, probiotics, and vitamins, often together with alkali, that are classified within the dietary supplementation category. The majority of dietary supplements claiming to treat or prevent kidney stones contain ingredients with conflicting or no scientific evidence to support their claims. Clinicians should advise stone formers that the effects of most supplements are unknown or unstudied in humans and that the absence of evidence does not imply absence of potential harm. Unfortunately, the CAM preparation consists of a mix of different molecules, often including alkali, with different potential mechanisms of action and, even when favorable results are reported, the role of the single molecules cannot be assessed. Despite all these concerns, CAM products remain quite popular among kidney stone patients. The scarce knowledge in this field prevents one from recommending CAM products in daily clinical practice; only a weak suggestion for their use in kidney stone patients may be reasonable.

The correct management of energy intake is crucial in CKD (chronic kidney disease) patients to limit the risk of protein energy wasting especially during low-protein regimes, but also to prevent overweight/obesity. The aim of this study was to assess the energy requirement of older CKD patients using objective measurements. This cross-sectional study enrolled 67 patients (aged 60–86 years) with CKD stages 3–5 not on dialysis, all of whom were metabolically and nutritionally stable. All patients underwent indirect calorimetry and measurement of daily physical activity level expressed by the average daily Metabolic Equivalent Task, using an accelerometer, in order to measure total energy expenditure (mTEE). Estimated TEE (eTEE) was derived from predictive equations for resting energy expenditure and physical activity levels coefficients. The mTEE were lower than eTEE-based on Harris–Benedict or Schofield or Mifflin equations (1689 ± 523 vs. 2320 ± 434 or 2357 ± 410 or 2237 ± 375 Kcal, p &lt, 0.001, respectively). On average mTEE was 36.5% lower than eTEE. When eTEE was recalculated using ideal body weight the gap between mTEE and eTEE was reduced to 26.3%. A high prevalence of a sedentary lifestyle and reduced physical capabilities were also detected. In conclusion, our data support the energy intake of 25–35 Kcal/Kg/d recently proposed by the NKF-KDOQI (National Kidney Foundation-Kidney Disease Improving Quality Initiative) guidelines on nutritional treatment of CKD, which seem to be more adequate and applicable than that of previous guidelines (30–35 Kcal/Kg/d) in elderly stable CKD patients with a sedentary lifestyle. According to our findings we believe that an energy intake even lower than 25 Kcal/Kg/d may be adequate in metabolically stable, elderly CKD patients with a sedentary lifestyle.

Background: No study has explored the limitations of current long-term management of hyperkalemia (HK) in outpatient CKD clinics. Methods: We evaluated the association between current therapeutic options and control of serum K (sK) during 12-month follow up in ND-CKD patients stratified in four groups by HK (sK ≥ 5.0 mEq/L) at baseline and month 12: Absent (no-no), Resolving (yes-no), New Onset (no-yes), Persistent (yes-yes). Results: We studied 562 patients (age 66.2 ± 14.5 y, 61% males, eGFR 39.8 ± 21.8 mL/min/1.73 m2, RAASI 76.2%). HK was “absent” in 50.7%, “resolving” in 15.6%, “new onset” in 16.6%, and “persistent” in 17.1%. Twenty-four hour urinary measurements testified adherence to nutritional recommendations in the four groups at either visit. We detected increased prescription from baseline to month 12 of bicarbonate supplements (from 5.0 to 14.1%, p &lt, 0.0001), K-binders (from 2.0 to 7.7%, p &lt, 0.0001), and non-K sparing diuretics (from 34.3 to 41.5%, p &lt, 0.001), these changes were consistent across groups. Similar results were obtained when using higher sK level (≥5.5 mEq/L) to stratify patients. Mixed-effects regression analysis showed that higher sK over time was associated with eGFR &lt, 60, diabetes, lower serum bicarbonate, lower use of non-K sparing diuretics, bicarbonate supplementation, and K-binder use. Treatment-by-time interaction showed that sK decreased in HK patients given bicarbonate (p = 0.003) and K-binders (p = 0.005). Conclusions: This observational study discloses that one-third of ND-CKD patients under nephrology care remain with or develop HK during a 12-month period despite low K intake and increased use of sK-lowering drugs.

IgG4-Related Disease (IgG4-RD) is a fibroinflammatory condition characterized by a typical histopathological pattern (dense lymphoplasmacytic infiltrate with prevalent IgG4+ plasma cells and storiform fibrosis), which may involve the kidney both directly (IgG4-related kidney disease, IgG4-RKD) or indirectly, as a consequence of post-renal ureteral obstruction due to retroperitoneal fibrosis (IgG4-RD RF). The most frequent presentation of IgG4-RKD is IgG4-related tubulointerstitial nephritis (TIN), but a glomerular disease can be present, in most of the cases a membranous nephropathy. Albeit steroid-responsive, in some cases renal manifestations may lead to progressive and permanent organ damage. In this review we describe four clinical cases representative of typical and less typical renal manifestations of IgG4-RD, emphasizing a potential, subclinical, early involvement of the kidney in the disease.

Background and Aims Steroid therapy is efficient in inducing remission of IgA nephropathy (IgAN) and preventing end stage renal disease (ESRD) but there are concerns about their safety. The TESTING trial in particular has been stopped early because of a higher incidence of side effects than conservative treatment thus inducing a conservative therapy with RAAS (renin angiotensin antagonist system) blockers. The aim of this analysis was to evaluate the incidence of adverse events (AE) in a retrospective observational trial on the real clinical practice. Method We evaluated 1209 patients (pz) with IgAN coming from 48 Italian centers: 285 pz in RAAS blockers alone, 732 treated for 6 months with steroid and 192 with a combination of steroid and other immunosuppressants (also with RAAS blockers). The analysis was limited to the 6 months of therapy. Results The basal characteristics of the 3 groups are shown in the table below. The figure shows the frequencies of 69 adverse events related with immunosuppression: the most frequent were infections (23, 2.73% of all patients, 34.3% of all AE), impaired glycemic control (11, 0.91% of patients, 16% of all AE), severe hypertension (6, 8.7% of all AE) and leukopenia (9, 0.80% of patients, 13% of all AE). Infections were observed in 16 (2.19%) pz in steroid therapy and 7 (3.65%) pz in steroid+immunosoppressive treatment. Liver toxicity and and gastrointestinal AE were observed almost in pz receiving steroid+ immunosuppressants [1(0.14%) and 2 (1.04%) pz, respectively]. 7 pz in steroid therapy (0.96%) and 2 in steroid+ immunosuppressants experienced an impaired glycemic control. All the 9 cases of leucopenia were registered in pz in steroid+ immunosuppressants (4.69%). A slightly higher incidence of allergies was observed in the RAAS blocker group (20 cases, 0.7%). The higher rates of infections and leucopenia were observed in pz above 70 years of age (6.12%,p Conclusion the incidence of EA in our observational study is lower than that observed in the TESTING and STOP trials (5.71% vs 14.7% and 40%, respectively). The most frequent AE were almost observed in oldest subjects with impaired renal function on steroid+other immunosuppressants. Though this trial is not randomized nor controlled (RC), it considers a large cohort of pz coming from the real clinical practice of the Italian Nephrology Units and demonstrates that the significantly lower incidence of steroid related AE than that observed in some RC trials doesn’t justify the abstention from steroids in IgAN at risk of progression. Much more attention should be paid in elderly pts with severe renal dysfunction with a closer follow-up, dose adjustments and antibiotic prophilaxis.

Background Gastro-intestinal manifestations in systemic lupus erythematosus (SLE) can affect up to 40% of patients, including enteritis presenting as mesenteric vasculitis, pseudo-obstruction or protein-losing enteropathy. We present a case of lupus enteritis successfully treated with anti-TNFalpha inhibitor. Methods A 28-year-old woman was evaluated for diarrhea, abdominal pain, fever and rectal bleeding not responsive to antibiotics. She had a thirteen-year history of SLE in remission with Mycophenolate Mofetil and previous muco-cutaneous and haematologic relapses, myocarditis and end-stage renal disease (IV-class glomerulonephritis). She previously underwent multiple immunosuppressants including ciclophosphamide, cyclosporine,anti-CD20, immunoglobulins. One month before the onset of symptoms she discontinued MMF for worsening anemia. Simultaneously we reported signs of lupic flare (low C3, haemolytic anemia, lymphopenia, fever, arthralgias and malar rash). Pulse-steroids and IVIg followed by cyclosporine were initially performed with only temporary benefit. Enteric CT-scan and endoscopy revealed chronic and acute colo–rectal and gastric inflammation (cryptitis, erosions, necrosis, microgranulomas). Anti-TNFalpha inhibitor Infliximab (5 mg/kg) was added to Azathioprine 50 mg/daily. Within a month we observed clinical and serological sustained remission. Results Typically, mesenteric vasculitis involves small arteries or venules. Histological examination reveals submucosal and muscular layers infiltration and necrotizing vasculitis, with panmural predominant eosinophilic, neutrophilic or mixed infiltrate. The distinction of inflammatory bowel disease (IBD) from enteric-SLE can be challenging. In this case, an early anti-flogistic therapy may have led to uncomplete microscopic patterns not fullfilling criteria neither for enteric vasculitis nor IBD. A lupic flare with predominant gastro-enteric presentation is the most plausible hypothesis because of the infrequent association between SLE and IBD and simultaneous extra-intestinal lupic features. Abdominal involvement in a patient previously treated with high dosage cyclophosphamide (10 g) and the lack of response to azathioprine lead to the introduction of anti-TNFalpha inhibitor. Conclusion The role of TNFalpha in SLE is controversial and TNFalpha inhibitors are reported to control SLE-arthritis. Further studies are needed to evaluate their role in the management of gastro-enteric SLE.

Purpose: Vascular access surveillance in hemodialysis is today an important challenge for nephrologist. Low blood flow is a risk factor for development of thrombosis of native fistula or graft. The aim of the study is to evaluate the correspondence between flow measurement by thermodilution and Color Doppler, and to identify flow rate values using the Blood temperature monitor (BTM) method in the case of stenosis. Methods: We evaluated 29 patients on chronic hemodialysis. The evaluation of blood flow with BTM were performed during the first hour of the hemodialysis session. All patients underwent a color doppler of vascular access within 10 days from the BTM measurements. Results: The mean vascular access flow calculated with BTM resulted 1142 ± 700 ml/min and there was a correlation with color doppler data 1199 ± 644 ml/min (p=0,0001 r=0,829). The flow of patients with hemodynamically significant stenosis was 332 ± 92 ml/min with a minimum value of 270 ml/min and a maximum value of 440 ml/min. Conclusion: the correspondence between thermodilution and color doppler support the implementation of intradialitic evaluation of the vascular access blood flow with the BTM method. Thermodilution allows to identify earlier patients with high risk of vascular access failure and the need for further diagnostic and therapeutic investigations.

The beneficial effects of vegetarian diets are known in the general population and in patients with chronic kidney disease (CKD). In recent years, the market has developed a number of processed plant-based products because of several factors (lifestyle changes, ethical concerns, and sustainability). The composition in terms of nutrients, ingredients, and additives of 560 products available on the market and on online shopping sites was analyzed to understand the characteristics of these products. Processed plant-based meat substitutes have a higher content of salt (+467%), lipids (+26%), mostly unsaturated, and fiber with respect to regular animal-based ones. Protein content is lower (−40%) in plant-based products with respect to corresponding animal ones. Of the 49 additives on the label (on average 2 per product), 20 contain phosphorus, sodium, potassium, or nitrogen. Several plant-based processed products may contain elevated amounts of salt and additives, which make them not optimal for CKD patients. Although a plant-based diet remains a very important tool for CKD nutritional management, patients should be aware regarding the extra content of sodium and additives in processed plant-based products compared to animal-based processed food.

Background and Aim: Obesity, dyslipidemia, hypertension and glucose intolerance are some of the main nutritional and metabolic problems that occur in post-transplant patients. We evaluated the daily dietary intake in renal transplant recipients to assess whether they fulfil the nutrient intake recommendations (according to the Italian recommended dietary allowances, LARN 2014). Subjects and Methods: Renal allograft recipients that were transplanted between 6 months and 5 years before this study were recruited. The daily intake of nutrients, including protein and salt, was estimated with a five-day food diary. Results: In total, 50 patients were studied (31 males and19 females); the mean patients’ age was 48.9±9.9 years, the mean age at transplant was 20.5±15.2 years (median 15.3 y) and the mean eGFR was 56.4±20.2 mL/min/1.73m2, with the eGFR terziles defined as >66.7, between 44.6 and 66.7, and

Drugs and food interact mutually: drugs may affect the nutritional status of the body, acting on senses, appetite, resting energy expenditure, and food intake; conversely, food or one of its components may affect bioavailability and half-life, circulating plasma concentrations of drugs resulting in an increased risk of toxicity and its adverse effects, or therapeutic failure. Therefore, the knowledge of these possible interactions is fundamental for the implementation of a nutritional treatment in the presence of a pharmacological therapy. This is the case of chronic kidney disease (CKD), for which the medication burden could be a problem, and nutritional therapy plays an important role in the patient’s treatment. The aim of this paper was to review the interactions that take place between drugs and foods that can potentially be used in renal patients, and the changes in nutritional status induced by drugs. A proper definition of the amount of food/nutrient intake, an adequate definition of the timing of meal consumption, and a proper adjustment of the drug dosing schedule may avoid these interactions, safeguarding the quality of life of the patients and guaranteeing the effectiveness of drug therapy. Hence, a close collaboration between the nephrologist, the renal dietitian, and the patient is crucial. Dietitians should consider that food may interact with drugs and that drugs may affect nutritional status, in order to provide the patient with proper dietary suggestions, and to allow the maximum effectiveness and safety of drug therapy, while preserving/correcting the nutritional status.

Purpose: The use of tyrosine kinase inhibitors (TKIs) in thyroid cancer patients is often limited by toxicities. Some have a long-term onset and potentially could impact patients’ survival. Among them, there is the nephrotoxicity, mainly represented by proteinuria. The aim of the study was to evaluate the prevalence of proteinuria in medullary thyroid cancer patients treated with cabozantinib, to examine whether it could be a marker for treatment monitoring and to evaluate histological kidney alterations. Methods: We collected data of 31 medullary thyroid cancer patients enrolled in the EXAM trial. Proteinuria was defined and evaluated using the National Cancer Institute’s Common Terminology Criteria for Adverse Events. In two symptomatic cases with high-grade proteinuria, a kidney biopsy was performed. Results: Proteinuria was observed in 4/18 patients (22.2%) and occurred after a mean period of 38months (median: 35.5months). It was significantly associated with previous chemotherapy (p = 0.005) and/or treatment with other TKIs (p = 0.04), a prolonged use of cabozantinib (p = 0.0004), and a better radiological response at the end of follow-up (p = 0.002). The kidney biopsy showed pathognomonic features of thrombotic microangiopathy in both cases and a focal amyloid deposit in one. Conclusion: Proteinuria is a quite frequent adverse event during cabozantinib treatment. It is relatively well manageable with the early detection and correction of risk factors, the temporary discontinuation of cabozantinib and/or its dose reduction, and the use of anti-proteinuric and renoprotective drugs in patient with hypertension. The histological findings confirmed some typical features of the anti-VEGF inhibition injury, already described for other TKIs.

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.

Background: Sarcopenia is a widespread concern in chronic kidney disease (CKD) as well in elderly patients and is one of the main reasons why low-protein diets for this population are controversial. The aim of this study was to assess the prevalence and correlates of sarcopenia among elderly male patients affected by CKD followed up in an outpatient nephrology clinic, where moderate protein restriction (0.6&ndash, 0.8 g/Kg/day) is routinely recommended to patients in CKD stage 3b-5 not on dialysis. Methods: This observational study included 80 clinically-stable male out-patients aged &gt, 60, affected by stage 3b-4 CKD. Forty patients aged &ge, 75 (older seniors) were compared to the other forty patients aged 60&ndash, 74 (younger seniors). All patients underwent a comprehensive nutritional and functional assessment. Results: Older seniors showed lower serum albumin, hand-grip strength, body mass index (BMI), skeletal muscle mass, and resting energy expenditure. Protein intake was significantly lower in older seniors whereas energy intake was similar. Average daily physical activity was lower in the older seniors than in the younger ones. Sarcopenia was more prevalent in older than in younger seniors. Among older seniors, sarcopenic and non-sarcopenic ones differed in age and performance on the Six-Minute Walk test, whereas the estimated glomerular filtration rate (eGFR), biochemistry, dietary protein, and energy intakes were similar. Conclusions: Older senior CKD male patients have lower muscle mass, muscle strength, and physical capacity and activity levels, with a higher prevalence of sarcopenia than younger patients. This occurs at the same residual renal function and metabolic profile and protein intake. Energy intake was at the target in both subgroups. In this CKD cohort, sarcopenia was associated with age and physical capacity, but not with eGFR or dietary intakes.

La nutrizione è considerata dalla legislazione sanitaria corrente parte integrante della prevenzione e terapia clinica, e quindi del processo assistenziale. In questa ottica il servizio di ristorazione di un ospedale rappresenta un potente ausilio terapeutico ed educazionale. Il servizio di ristorazione della nostra Azienda Ospedaliera-Universitaria Pisana si basa sul Dietetico, una raccolta di diete standardizzate a composizione bromatologica definita, nel quale vengono indicate anche le finalità e le caratteristiche dei pazienti a cui si rivolge. Questo articolo riporta la nostra esperienza in questo settore, con particolare riguardo alle diete speciali per i pazienti nefropatici. Le diete speciali, come la dieta ipoproteica (0.6 g/kg p.c./die) ipofosforica, la dieta ipoproteica (0.7 g/kg p.c./ die) vegetariana e la dieta fortemente ipoproteica (0.3 g/kg p.c./die) ipofosforica sono prescritte dal medico, elaborate dal dietista e formulate per il singolo paziente. Sin dalla sua preparazione la dieta speciale ipoproteica presenta diversi punti critici (elaborazione-confezionamento e distribuzione della dieta, mancata personaliz-zazione, prodotti artificiali aproteici). Allo scopo di migliorare il servizio dietetico abbiamo rilevato l'effettivo consumo e la gradevolezza dei pasti speciali ipoproteici distribuiti durante la degenza mediante la compilazione di due schede consegnate ai pazienti nel corso della degenza. Nel complesso i risultati indicano una buona accettazione delle diete da parte dei pazienti, ma con un ridotto consumo in particolare riguardante il pane aproteico.

At the 17th national meeting of the “Peritoneal dialysis” Study Group (Italian Society of Nephrology), held in Montecatini Terme (20–22 March, 2014), 141 physicians received a questionnaire to surv...

Objective To evaluate the long-term renal function, continence, and voiding function in 64 patients, surviving for 5 or more years after W-shaped ileal neobladder with a short afferent limb and refluxing ureterointestinal anastomoses. Materials and Methods Kidney morphology and function were evaluated using nuclear renography, creatinine, and glomerular filtration rate. Continence and voiding function were evaluated with a diary on frequency, voided volumes, number of pads, and with the incontinence severity index (ISI) questionnaire, the American Urological Association-Symptom Index (AUA-SI), and the American Urological Association-Symptom Problem Index. Results The renal scan showed a dilatation of the upper urinary tract in 4.8% of renoureteral units. Of the patients, 12.5% voided with intermittent or permanent catheterization. The remaining 87.5% voided spontaneously; 75% did not use pads, 12.5% used protection for safety, 7.1% 1 pad, and 5.4% more than 1 pad, during the day; during night, 55.3% did not use pads, 23.2% used protection for safety, and 12.6% and 8.9% 1 or more than 1 pad. The ISI questionnaire showed that 35.7% were fully continent, whereas 41%, 12.5%, and 10.8% had slight, moderate, and severe incontinence. The AUA-SI showed that 50% had mild, 39.3% moderate, and 10.7% severe lower urinary tract symptoms. Urinary incontinence, daytime frequency, and nocturia correlated positively with the age of patients at follow-up and negatively with voided volume. Conclusion Long-term detrimental effect on renal function of orthotopic neobladder with no antireflux anastomoses is limited. Long-term continence and voiding function results are satisfactory. The ISI questionnaire might be useful to evaluate and grade incontinence in patients with orthotopic neobladder, whereas the AUA-SI has many limitations.

Delayed graft function is a complication in the early posttransplant period that impacts the short and long-term graft outcome. It may be related to different factors that include center, recipient, or donor features. The etiology is still controversial, although different pathophysiologic mechanisms have been implicated. There is no effective treatment; however, early diagnosis and therapeutic interventions may reduce the consequence of this complication.

Background Dietary treatment is helpful in CKD patients, but nutritional interventions are scarcely implemented. The main concern of the renal diets is its feasibility with regards to daily clinical practice especially in the elderly and co-morbid patients. This study aimed to evaluate the effects of a pragmatic, step-wise, personalized nutritional support in the management of CKD patients on tertiary care. Methods This is a case-control study. It included 823 prevalent out-patients affected by CKD stage 3b to 5 not-in-dialysis, followed by tertiary care in nephrology clinics; 305 patients (190 males, aged 70 ± 12 years) received nutritional support (nutritional treatment Group, NTG); 518 patients (281 males, aged 73 ± 13 years) who did not receive any dietary therapy, formed the control group (CG). In the NTG patients the dietary interventions were assigned in order to prevent or correct abnormalities and to maintain a good nutritional status. They included manipulation of sodium, phosphate, energy and protein dietary intakes while paying special attention to each patient’s dietary habits. Results Phosphate and BUN levels were lower in the NTG than in the CG, especially in stage 4 and 5. The prevalence of hyperphosphatemia was lower in the NTG than in CG in stage 5 (13.3 % vs 53.3 %, p

Nutrition is considered by the National Health Authorities as part of the clinical care process. In this perspective, the catering service of a hospital represents a powerful therapeutic and educational aid for the in-patients.The catering service of our University Hospital in Pisa is based on a collection of standardized diets with indications concerning the type of patient which they are addressed. The present paper deals with our experience in this field, and in particular with the diets for renal patients.The so called “special” diets, such as low protein (0.6 g / kg b. w. / day) low phosphorus diet, the low protein (0.7 g / kg b.w./ day) vegetarian diet and the very low protein (0.3 g / kg b. w./day) low phosphorus diet are prescribed by the doctors and developed by the dietician for the individual patient.Since its preparation, the low-protein diets have several critical points, namely processing - packaging and distribution of the diet, no customization, the low protein artificial foods).In order t...

Hyperkalemia is a frequent electrolyte disturbance in patients on dialysis or non-dialysis CKD patients, including those using renin-angiotensin system inhibitor drugs. Sodium polystyrene sulfonate (SPS; Kayexalate) is a resin widely used for hyperkalemia treatment. Unfortunately, its use entails some serious unwanted gastrointestinal side effects. We report the case of a 64-year-old male diabetic patient, suffering from ESRD on hemodialysis, who was treated with 30 g of Kayexalate twice a week (long interdialytic interval). This is a quite common case in the clinical practice. The patient experienced an episode of rectal bleeding followed by the diagnosis of non-specific colitis through colonoscopy. Histological examination, showed the presence of crystals of Kayexalate in the colonic mucosa leading to the suspect of iatrogenic intestinal damage caused by Kayexalate administration. Treatment with SPS was stopped. Nevertheless crystals remain evident in the intestinal mucosa in a colonoscopy performed 14 months later due to a new episode of rectal bleeding. Two years after the first episode the patient died because of intestinal infarction. The review of the literature highlights the risk of serious side effects such as necrotizing colitis with perforation both for the drug in sodium phase and in calcium phase. New intestinal potassium-binger agents, apparently without intestinal severe side effects, are under clinical evaluation. This case does not assess if the crystals deposited in the colonic mucosa are inert or have contributed to the final event, but it shows that Kayexalate is a drug with potential harmful effect even when used orally, at very low dosage and without sorbitol. In our opinion, the SPS should be prescribed carefully, especially as chronic administration, and the prescription should be limited to real and pressing requirements.

In occasione del XVII convegno nazionale del Gruppo di Studio SIN “Dialisi Peritoneale”, svoltosi a Montecatini Terme (20–22 Marzo 2014), è stato distribuito un questionario a 141 medici con l'intento di rilevare le opinioni dei nefrologi italiani sulla problematica dell'attività fisica nei pazienti in dialisi peritoneale, e sulle “barriere” che ne impediscono lo sviluppo. La totalità del campione intervistato concorda sull'utilità dell'esercizio fisico e sulla necessità di incrementarlo nella popolazione dialitica. Il 90% degli intervistati reputa che l'attività fisica sia un'importante problematica clinica, e il 78% riesce a trovare il tempo per informarsi riguardo le abitudini del paziente in merito all'esercizio. La maggioranza degli intervistati (61%) ritiene il paziente interessato e, se opportunamente stimolato, disposto ad incrementare l'esercizio fisico (64%). Tuttavia, nonostante le preoccupazioni in merito alla sicurezza dell'attività fisica in dialisi (85%), non tutti si considerano capaci di effettuare una prescrizione in merito (78%). L'86% degli intervistati riferisce di fornire consigli in merito all'attività fisica ma di fornire solo raramente materiale informativo scritto (7%), consigliare al paziente specialisti del settore, e quasi mai di consegnare attrezzature atte a svolgere l'attività fisica indicata (3%). In conclusione, mentre traspare l'interesse a contrastare la sedentarietà e favorire l'attività fisica nei pazienti in dialisi peritoneale, la reale implementazione appare difficile e problematica. È quindi auspicabile una collaborazione scientifica e applicativa che coinvolga più gruppi di studio e più figure professionali dedicate allo sviluppo dell'attività ed esercizio fisico in dialisi peritoneale.