Search

Background Despite controversial evidence, intra-aortic balloon pump (IABP) is still the most used temporary mechanical support in cardiogenic shock (CS), as a bridge to recovery or to more advanced mechanical support and/or heart transplantation [1]. Indeed, the available evidence, which is mainly restricted to the context of acute coronary syndromes (ACS) and is limited by the variability of CS definitions, shows no benefit in terms of mortality [2]. Randomized controlled trials on IABP in the setting of non-ACS CS are still missing. As a result, European guidelines do not recommend the routine use of IABP, which may be considered in refractory CS [3]. Purpose The aim of our study was to analyse the use of IABP in the context of CS, providing insights into its indications, outcomes, and complications in relation to the aetiology (ACS vs non-ACS) of CS. Methods We retrospectively enrolled all consecutive adult patients receiving IABP for refractory CS at our tertiary referral Hospital between 2009 and 2018, and analysed data focusing on in-hospital outcomes, including death, recovery, heart transplantation, and escalation to more advanced mechanical support such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) or left ventricular assist device (LVAD), and on IABP-related complications. Results 403 patients received IABP, 75.2% (n=303) for ACS CS and 24.8% (n=100) for non-ACS CS. With respect to ACS patients, non-ACS patients were younger (age 59±18.3 vs 73.1±12.6 years old, p0.05]. The incidence of IABP-related overall and major complications (including ischemic stroke, major bleeding, and peripheral or visceral ischemia) was not different with respect to the non-ACS vs ACS aetiology [major complications: 8.0% (n=8) vs 5.0% (n=15), p>0.05]. Conclusions In our experience, in the clinical setting of CS treated with IABP, non-ACS patients show a worse clinical profile and prognosis than ACS patients, and more often require escalation to more advanced mechanical support and/or heart transplantation, while the incidence of IABP-related complications appears similar independently of the aetiology. Funding Acknowledgement Type of funding sources: None.

Cardiovascular disease is the main cause of morbidity and mortality in patients with chronic kidney disease (CKD) affected by a series of risk factors (hypertension, anemia, left ventricular hypertrophy, cardiac failure, and dyslipidemia). The combined presence of these factors raises the cardiovascular risk in CKD patients considerably compared with that of the general population. Nephrologists can play a role in preventing and treating these risk factors and thereby delaying the development of CKD. In preventing CKD, nephrologists who practice ultrasound techniques should have basic know-how of echocardiography so that they can screen CKD patients for early referral to a cardiologist. Echocardiography is a noninvasive ultrasound technique that requires adequately trained doctors to perform it. Nephrologists who practice it need to obtain good training and postgraduate certification of competence in echocardiography. These nephrologists should team up with cardiologists rather than replace them, and at the same time be aware that they possess the basic knowledge to manage cardiovascular disease in CKD patients.

non disponibile (Cardionephrology)

In this review we analyze the cardiorenal effects of hyperuricemia and try to answer the eternal question of whether it is or is not to be considered a true risk factor in addition to a well-established marker of cardiovascular, cerebrovascular and renal risk.

There is a great deal of data demonstrating a close association between chronic kidney disease (CKD) and cardiovascular disease, particularly coronary artery disease (CAD). About one half of deaths in patients with end-stage renal disease (ESRD) are of cardiovascular causes. The association between CKD and ischemic heart disease can be explained in part because both conditions are related to the traditional risk factors for atherosclerotic vascular disease. However, CKD might also have a casual role in the development and progression of CAD, with several mechanisms potentially involved. Among CAD patients, those with CKD have systematically a worse prognosis than those without CKD irrespective of the clinical presentation or the treatments applied. Current therapy is based on small trials and observational data and on the extrapolation of the strategies that have been proved useful in the general population, although many treatments that have been shown to improve the prognosis of CAD patients are underused in those with renal impairment. (Cardionephrology)

Is peritoneal ultrafiltration a useful therapeutic alternative in diuretic resistant heart failure, even in patients with preserved glomerular filtration rate?Some recent clinical trials, here briefly analysed, reported the positive effects of peritoneal ultrafiltration on NYHA class, hospitalization rates and quality of life of decompensated patients.Why this technique has so little fortune among Nephrologists?

La sindrome cardio-renale (SCR) è una sindrome clinica ben nota, che descrive tanto gli effetti negativi dell'insufficienza renale sull'equilibrio cardio-circolatorio quanto quelli dell'insufficienza cardiaca sulla funzione renale. Molti autori hanno studiato l'utilità di marcatori sierologici ai fini dell'identificazione e del monitoraggio ambulatoriale delle varie forme di questa sindrome. L'analisi dei livelli sierici dei peptidi natriuretici è, al momento, quella maggiormente utilizzata, in quanto essi stessi non sono solo direttamente associati alla gravità delhinsufficienza cardiaca, ma anche capaci di rilevare precocemente la disfunzione renale, certamente prima che sia possible osservare un incremento nei livelli sierici di creatinina. NGAL, cistatina C, NAG, KIM-1 e IL-18 rappresentano interessanti biomarcatori per la diagnosi precoce di danno renale acuto (AKI), e quindi per la diagnosi precoce delle forme renocardiache acute, mentre il loro utilizzo in altre forme di SCR non appare codificato. Al contrario, la valutazione di KIM-1 e IL-18 sembra più utile per cercare una diagnostica differenziale tra forme diverse di insufficienza renale acuta. (Cardionephrology)

Cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmias, and sudden cardiac death represent main causes of morbidity and mortality in patients with chronic kidney disease (CKD). Their pathogenesis relates to the close linkage between heart and kidneys and involves both traditional and non-traditional risk factors. According to the well-established classification of cardio-renal syndrome, the cardiovascular involvement in chronic kidney disease is known as “type 4 cardiorenal syndrome” (chronic renocardiac syndrome).Uremic cardiopathy is mainly characterized by both left ventricular systolic and diastolic impairment, often associated to right heart dysfunction due to the presence of a vascular access for hemodialysis.The typical clinical picture is represented by left ventricular hypertrophy (LVH), the pathogenesis of which is multifactorial and closely linked to elevated blood pressure, vascular stiffness and atherosclerosis.The diagnosis is mainly made by ultrasound...

La fibrillazione atriale (FA) rappresenta la più comune forma di aritmia riscontrabile nella pratica clinica quotidiana, soprattutto nei pazienti affetti da cardiopatia ischemica cronica e da malattia renale cronica (CKD), ed è spesso correlata all’età avanzata e alla presenza di altre comorbidità, come ipertensione arteriosa, diabete mellito e vasculopatia polidistrettuale. Negli ultimi 20 anni si è assistito a un progressivo incremento dell’incidenza della fibrillazione atriale nei pazienti affetti da malattia renale cronica, soprattutto nei pazienti sottoposti al trattamento sostitutivo della funzione renale. (Cardionephrology)

La malattia di Fabry è una disfunzione lisosomiale ereditaria, nella quale l'accumulo cronico di globotriaosilceramide (Gb3) induce danno d'organo renale, cardiaco e neurologico. Trasmessa attraverso il cromosoma X, ha un'incidenza stimata che va da un caso ogni 55000 maschi nati vivi sino a uno ogni 3100. La terapia enzimatica sostitutiva si propone come trattamento di elezione di tale patologia, capace di modificarne la storia clinica in maniera sostanziale. Questa review si propone come uno stimolo a guardare con occhi da “cardionefrologi” a questa sindrome cardio-renale sistemica. (Cardionephrology)

Type 5 cardiorenal syndrome (CRS) is a recently defined clinical syndrome for which complete epidemiological data is still missing. Type 5 CRS occurs when heart and kidneys are involved at once. The pathophysiology of type 5 CRS depends on the underlying disease. Acute type 5 CRS results from systemic processes, e.g. sepsis, infections, drugs, toxins, and connective tissue disorders such as lupus, Wegener's granulomatosis, and sarcoidosis. By contrast, the chronic type 5 CRS (i.e. cirrhotic liver disease) has a more insidious onset, as the kidney and cardiac dysfunction may develop slowly until reaching a crucial point leading to full decompensation. Diagnosis is based both on serological (biomarkers of acute cardiorenal disease, creatinine, and GFR levels) and imaging methods (echocardiography and abdominal ultrasound). Therapy is based on management of the underlying disease and treatment of cardiorenal complications (fluid therapy, drugs, and renal replacement therapy devices).

Pulmonary hypertension is defined as an increased systolic pulmonary pressure of >30 mm Hg, and it shows a 40% prevalence in hemodialysis patients due to vascular access (both central venous catheter and arteriovenous fistula). Secondary pulmonary hypertension in chronic kidney disease patients is strictly related to pulmonary circulation impairment together with chronic volume overload and increased levels of cytokines and growth factors, such as FGF, PDGF, and TGF-β, leading to fibrosis. Endothelial dysfunction, together with lower activation of NOS, increased levels of serum endothelin and fibrin storages, involves an extensive growth of endothelial cells leading to complete obliteration of pulmonary vessels. Pulmonary hypertension has no pathognomonic and distinctive symptoms and signs; standard transthoracic echocardiography allows easy assessment of compliance of the right heart chambers. The therapeutic approach is based on traditional drugs such as digitalis-derived drugs, vasodilatory agents (calcium channel blockers), and oral anticoagulants. New pharmacological agents are under investigation, such as prostaglandin analogues, endothelin receptor blockers, and phosphodiesterase-5 inhibitors.

non disponibile (Cardionephrology)

Is peritoneal ultrafiltration a useful therapeutic alternative in diuretic resistant heart failure, even in patients with preserved glomerular filtration rate? Some recent clinical trials, here briefly analysed, reported the positive effects of peritoneal ultrafiltration on NYHA class, hospitalization rates and quality of life of decompensated patients. Why this technique has so little fortune among Nephrologists? (Cardionephrology)

Calciphylaxis, better described as “Calcific uremic arteriolopathy” (CUA), involves about 1–4% of hemodialysis patients all around the world with high mortality rates. We describe a rare clinical case of CUA in peritoneal dialysis patient associated with urological disease. Penile calciphylaxis represents rare clinical complication, and an early diagnosis and multidisciplinary approach are requested. Pathogenesis is still unclear, and therapeutic approaches need more long-term clinical trials to test their efficacy and safety.

Cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmias, and sudden cardiac death represent main causes of morbidity and mortality in patients with chronic kidney disease (CKD). Their pathogenesis relates to the close linkage between heart and kidneys and involves both traditional and non-traditional risk factors. According to the well-established classification of cardio-renal syndrome, the cardiovascular involvement in chronic kidney disease is known as “type 4 cardiorenal syndrome” (chronic renocardiac syndrome). Uremic cardiopathy is mainly characterized by both left ventricular systolic and diastolic impairment, often associated to right heart dysfunction due to the presence of a vascular access for hemodialysis. The typical clinical picture is represented by left ventricular hypertrophy (LVH), the pathogenesis of which is multifactorial and closely linked to elevated blood pressure, vascular stiffness and atherosclerosis. The diagnosis is mainly made by ultrasound (2D and 3D echocardiography) and cardiac magnetic resonance imaging (CMRI), although echocardiography is most widely employed since it is non-invasive and cheaper than CMRI. The following chapter provides an overview of the epidemiology, pathophysiology, diagnosis, and treatment of left ventricular hypertrophy in CKD patients. (Cardionephrology)

La Sindrome Cardio-Renale (SCR) di Tipo 5 si configura come una sindrome clinica di recente classificazione e viene diagnosticata in un'ampia serie di patologie sistemiche, allorché si assiste a un contemporaneo interessamento secondario di rene e apparato cardiovascolare. I meccanismi fisiopatologici dipendono, sostanzialmente, dalla tempistica con la quale si manifesta una SCR di Tipo 5; ben diverso è il quadro di una forma acuta (sepsi, connettiviti, malattia di Wegener), che si manifesta rapidamente rispetto all'insorgenza della patologia primitiva, in contrasto con quello di una forma cronica (cirrosi epatica e sindrome epato-renale), che esordisce e si sviluppa subdolamente. La diagnosi si basa sul dosaggio dei livelli plasmatici di bio-marcatori di danno cardiaco e renale e sulle tecniche di diagnostica per immagini (ecocardiografia, ecografia addominale). La terapia deve mirare al trattamento della patologia di base e a quello delle complicanze cardio-renali. (Cardionephrology)

TAPSE measurement during echocardiography is a well known measure of right heart systo-diastolic function. Low TAPSE means reduced cranio-caudal excursion of tricuspidal annulus, sign of both reduced ejection fraction and reduced distensibility of right ventricle. It is a good prognostic index for cardiac mortality risk in CHF patients, adding significant prognostic information to NYHA stadiation. Nephrologists do not always fully aware of right ventricular function in their patients affected by chronic renal failure (CRF), even if this datum is probably crucial in vascular access policy. Our study was designed to study right ventricle function and TAPSE on 202 patients affected by moderate chronic renal failure, free from overt pulmonary hypertension. TAPSE, PAPs, right chambers diameters, classical Framingham factors, estimated glomerular filtration rate were recorded. TAPSE was reduced (23 mm) in 43% of patients enrolled, while dilated right chambers were present in 24%. PAPs exceeded 30 mmHg in 29% of patients. Echocardiographic signs of left ventricular hypertrophy were found in 36% of patients. The ejection fraction was normal in all patients. Statistical analysis showed a significant indirect correlation between TAPSE and PAPs and between TAPSE and tele-diastolic diameters and volumes of the right ventricle, while a direct correlation was observed between TAPSE and Framingham score. TAPSE showed a bimodal distribution, with a subpopulation "low TAPSE - high PAPs", next to a population characterized by normal values ??for both parameters. A reduction in compliance and systolic function of the right heart chambers is quite early and frequent in course of CKD, a fact that the nephrologist should take in due consideration, managing blood volume or planning vascular access for hemodialysis.La misurazione dell'indice TAPSE nel corso di un esame ecocardiografico rappresenta un parametro ben codificato per la studio della funzione sisto – diastolica del cuore destro.Bassi valori di TAPSE indicano una ridotta escursione cranio – caudale dell'anulus tricuspidale, a sua volta indice di ridotta frazione d’eiezione e distensibilità del ventricolo destro.Al tempo stesso rappresenta un buon indice prognostico per il rischio di mortalità cardiovascolare in pazienti affetti da malattia renale cronica e conferisce ulteriore valore prognostico alla sola stadiazione NYHA.I nefrologi non sono ancora del tutto consapevoli dell’importanza dello studio della funzione ventricolare destra nei pazienti affetti da malattia renale cronica (CKD) anche se il dato sembra essere cruciale soprattutto in vista di una buona politica riguardante il confezionamento dell’accesso vascolare per emodialisi.Il nostro studio è stato progettato per valutare la funzione ventricolare destra e la TAPSE in 202 pazienti affetti da Malattia Renale Cronica di grado moderato senza segni clinici evidenti di ipertensione polmonare.Sono stati presi in considerazione i seguenti parametri: TAPSE, PAPs, diametri delle sezioni cardiache di destra, fattori di rischio di Framingham e stima della frazione di filtrazione glomerulare.I valori di TAPSE erano ridotti (23 mm) nel 43% dei pazienti arruolati, mentre il 24% dei pazienti esaminati presentava dilatazione delle camere cardiache di destra con PAPs superiori ai 30 mmHg nel 29% dei pazienti. Segni ecocardiografici di ipertrofia ventricolare sinistra sono stati riscontrati nel 36% dei pazienti. La frazione di eiezione era normale in tutti i pazienti studiati.L’analisi statistica dei dati ha evidenziato una significativa correlazione indiretta tra TAPSE e PAPs e tra TAPSE e diametri/volumi del ventricolo destro, mentre una correlazione diretta è stata trovata tra TAPSE e punteggio di Framingham.I valori di TAPSE si sono distribuiti in maniera bimodale con una sottopopolazione “a bassi valori di TAPSE ed alti valori di PAPs” vicina ad un’altra caratterizzata dalla presenza di valori normali per entrambi i parametri.Una riduzione della compliance e della funzione sistolica delle sezioni cardiache destre rappresenta un elemento precoce e frequente in corso di CKD, elemento che va tenuto in considerazione dai nefrologi allo scopo di controllare in maniera ottimale lo stato d’idratazione dei pazienti e pianificare una buona politica di allestimento di un accesso vascolare per emodialisi.

The term cardiorenal syndrome (CRS) describes a broad spectrum of clinical conditions with four combinations of acute and chronic heart and kidney failure. Based on the pathophysiological primum movens, the actual classification recognizes five CRS types: in type I and II CRS, the initiating event is heart failure (acute or chronic), while it is kidney failure in type III and IV CRS; type V is linked to systemic diseases. Ultrasound techniques (echocardiography and ultrasonography of the kidney, inferior vena cava and chest) can be extremely helpful in establishing a prompt diagnosis and a correct CRS classification. Basic echocardiography allows evaluation of ventricular diastolic and systolic functions, investigates pulmonary congestion and pericardial effusion, and describes volume overload. On the other hand, renal ultrasound helps clinicians to distinguish between acute and chronic renal failure, excludes urinary tract dilation or pathological bladder repletion, and provides crucial information regarding kidney volume or echogenicity. Applying basic knowledge of echocardiography and renal ultrasound, nephrologists may be in a better position for patient treatment and management, bearing in mind that doctors can properly use a stethoscope although not being a cardiologist.

Introduction: Chronic kidney disease (CKD) is a widespread invalidating condition, leading to erythropoietin deficiency and decreased cardiovascular performance. Darbepoetin-α and epoetin-α are extensively used to correct renal anemia. The aim of this study was to evaluate cardiological outcomes in two groups of CKD patients treated with erythropoiesis-stimulating agents (ESA: 20 µg darbepoetin-α weekly vs. 2,000 IU epoetin-α thrice weekly) with an unconventional 1:300 conversion ratio. Methods: The study was designed as a single center, retrospective, observational study. One hundred stage IV CKD patients were selected. Hemoglobin (Hb), hematocrit, C-reactive protein, pro-brain natriuretic peptide (BNP) and basal echocardiograms were monitored every 3 months. Results: Darbepoetin-α was significantly more effective in increasing Hb levels after 3 (p < 0.0001), 6 (p < 0.0001), 9 (p < 0.01) and 12 months (p < 0.01) compared to epoetin-α. The optimal Hb target level (11 g/dl < Hb < 12 g/dl) was completely reached after 1 year of treatment with darbepoetin-α and in 70% of the patients treated with epoetin-α (p < 0.01). Cardiovascular performance (left ventricular end-diastolic volume, ejection fraction and pro-BNP) was significantly improved after darbepoetin-α treatment at the 6- and 12-month follow-ups compared to epoetin-α. Discussion: Despite the limitations of a retrospective observational study, these results encourage nephrologists to test the 1:300 darbepoetin/epoetin conversion ratio in ‘easy’ patients, and aggressive protocols for the treatment of anemia in CKD patients are avoided. Darbepoetin-α appeared effective in anemia correction, improving cardiovascular performance in a significantly higher proportion than epoetin. At low doses, on the other hand, it has to be borne in mind that a treatment regimen with only one submaximal administration per week may increase patient compliance and adherence to therapy, explaining in part the observed results.

We present a simulation study of the performance of two multicast routing protocols, AMRIS (ad hoc multicast routing protocol utilizing increasing ID-nurnbers) and ODMRP (on-demand multicast routing protocol), in the presence of the rate adaptation mechanism of the IEEE 802.11b MAC protocol. We have chosen these two protocols because they are representative of the different multicast routing strategies proposed in the literature, the tree-based approach and the mesh-based approach. To evaluate the performance of these protocols, we have considered figures of merit, such as packet delivery fraction and energy spent by the network.

n/a

Ce texte a fait l'objet d'une communication au XXXIIIe Congrès International de l'Association des Sociétés de Philosophie de Langue Française (A.S.P.L.F.), (Venise, île de San Servolo, 17-21 août 2010); International audience

La version complète de cette conférence, présentée au XXXIIIème Congrès International de l'Association des Sociétés de Philosophie de Langue Française (A.S.P.L.F.), a été publiée dans L. Palumbo (a cura di), Logon didonai. La filosofia come esercizio del render ragione. Studi in onore di Giovanni Casertano, Napoli, Loffredo Editore, "Skepsis, n° 24", 2011, pp. 205-219.; International audience

The effect of broccoli extract (BE)-enriched diet was studied in order to evaluate its ability to counteract liver cholesterol oxidation products (COPs) induced by acute strenuous exercise in rats. Thirty-two female Wistar rats were randomly divided into four groups: control diet without exercise (C), BE-enriched diet without exercise (B), control diet with acute exhaustive exercise (S) and BE-enriched diet with acute exhaustive exercise (BS). The study lasted 45 days and on the last day, rats of S and BS groups were forced to run until exhaustion on a treadmill. Glutathione-S-transferase (GST), glutathione reductase (GR), glutathione peroxidase (GPx), catalase (CAT) and cholesterol oxidation products (COPs) were determined in liver. Exhaustive exercise was clearly responsible for tissue damage, as evidenced by the increase of lactate dehydrogenase (LDH) plasma activity increase in the S group rats. Moreover, the exercise protocol reduced CAT activity in liver, while it did not affect GST, GR and GPx. The BE-enriched diet increased raised GST, GR and CAT activities in rats of BS group. The main COPs found were 7α-hydroxycholesterol, 7β-hydroxycholesterol, 7-ketocholesterol, cholestanetriol, 24-hydroxycholesterol and 27-hydroxycholesterol. The BE-enriched diet led to reduced cholesterol oxidation following exhaustive exercise; the highest level of COPs was found in the S group, whereas the BS rats showed the lowest valueamount. This study indicates that the BE-enriched diet increases antioxidant enzyme activities and exerts an antioxidant effect towards cholesterol oxidation in rat liver, suggesting the use of phytochemicals in the prevention of oxidative damage and in the modulation of the redox environment.