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Introduction: Cardiovascular disease is one of the main causes of morbidity and mortality in patients with autosomal dominant polycystic kidney disease (ADPKD). Autonomic dysfunction is associated with an increased risk for all cardiovascular events in the general population and can be evaluated with heart rate variability (HRV). Objective: To evaluate HRV in ADPKD patients with mild hypertension versus hypertensive patients with organ damage and healthy controls (HC). Materials and Methods: We have enrolled 65 patients: 21 ADPKD patients (10 males), 20 patients with hypertension (14 males), and 24 HC (10 males). Biochemical analysis, clinical evaluation, anthropometric data, intima-media thickness, 24-h ECG Holter recording, and echocardiography were investigated at the time of enrollment. Results: No significant differences in HRV parameters were found between ADPKD with mild hypertension and hypertensive patients with organ damage. The median of HRV variables in time domain as SDNN (global autonomic activity) was significantly lower in ADPKD and hypertensive patients than HC (p < 0.05). In the frequency domain analysis, low frequency (LF), which mainly reflects the sympathetic component, showed higher values in ADPKD and hypertensive patients than HC during the night (p < 0.01). During the night, the sympathovagal balance, LF/high frequency (HF), showed higher values in ADPKD and hypertensive patients than HC (p < 0.0001). Conversely, LF day was lower in ADPKD and hypertensive patients than HC (p < 0.01). HF, which mainly reflects the parasympathetic component, was lower in ADPKD and hypertensive patients during the night than HC (p < 0.0001). Conclusions: HRV reduction is present in ADPKD patients with mild hypertension in the absence of organ damage. The evaluation of sympathovagal balance can provide novel information on the cardiovascular risk in ADPKD patients in addition to classical risk factors.

A relationship between dysbiotic gut microbiome and chronic kidney disease (CKD) has been recently documented, it contributes to CKD-related complications, including cardiovascular disease. Aim: We tested how a low-protein diet (LPD)&mdash, with or without oral inulin supplementation as a prebiotic&mdash, modulates some inflammatory, atherosclerosis and endothelial dysfunction indices and nutritional markers, as well as psychocognitive functions in CKD patients. We conducted a prospective, case&ndash, control study on CKD patients on conservative therapy, divided in two groups: the intervention group treated with LPD (0.6 g/kg/day) plus inulin (19 g/day) and a control group treated with LPD without inulin, for six consecutive months. Clinical and hematochemical parameters as well as instrumental, and psychocognitive assessments (by SF-36 survey and MMSE, HAM-D, BDI-II) were recorded in all the participants at baseline (T0), at three months (T1) and at six months (T2). A total of 41 patients were enrolled: 18 in the intervention group and 23 in the control group. At T2, in both groups, we observed a significant reduction of serum nitrogen and phosphorus (p &le, 0.01) and serum uric acid (p &le, 0.03), and an improvement in metabolic acidosis (bicarbonates, p &le, 0.01, base excess, p &le, 0.02). Moreover, at T2 the intervention group showed a reduction in serum insulin (p = 0.008) and fasting glucose levels (p = 0.022), HOMA-IR (p = 0.004), as well as lower total serum cholesterol (p = 0.012), triglycerides (p = 0.016), C-reactive protein (p = 0.044) and homocysteine (p = 0.044) and higher HDL (p &lt, 0.001) with respect to baseline. We also observed a significant amelioration of some quality of life and functional status indices (SF-36 survey) among the intervention group compared to controls, without a significant improvement in the cognitive state (MMSE). On the other hand, an amelioration in mood (by HAM-D and BDI-II) was found in the intervention group and in controls (only by BID-II). In conclusion, LPD in association with oral inulin supplementation improved glycemic and lipid metabolism and ameliorated the systemic inflammatory state, likely reducing cardiovascular risk in CKD patients and this may represent a promising therapeutic option, also improving quality of life and mood.

Introduction: The gut microbiota has coevolved with humans for a mutually beneficial coexistence and plays an important role in health and disease. A dysbiotic gut microbiome may contribute to progression to chronic kidney disease (CKD) and CKD-related complications such as cardiovascular disease. Microbiota modulation through the administration of prebiotics may represent an important therapeutic target. Aim: We sought to evaluate the effects of a low-protein diet (LPD) (0.6 g/kg/day) with or without the intake of the prebiotic inulin (19 g/day) on microbiota and clinical parameters in CKD patients. Materials and Methods: We performed a longitudinal, prospective, controlled, and interventional study on 16 patients: 9 patients treated with LPD (0.6 g/kg/day) and inulin (19 g/day) and 7 patients (control group) treated only with LPD (0.6 g/kg/day). Clinical evaluations were performed and fecal samples were collected for a subsequent evaluation of the intestinal microbiota in all patients. These tests were carried out before the initiation of LPD, with or without inulin, at baseline (T0) and at 6 months (T2). The microbiota of 16 healthy control (HC) subjects was also analyzed in order to identify potential dysbiosis between patients and healthy subjects. Results: Gut microbiota of CKD patients was different from that of healthy controls. The LPD was able to significantly increase the frequencies of Akkermansiaceae and Bacteroidaceae and decrease the frequencies of Christensenellaceae, Clostridiaceae, Lactobacillaceae, and Pasteurellaceae. Only Bifidobacteriaceae were increased when the LPD was accompanied by oral inulin intake. We showed a significant reduction of serum uric acid (SUA) and C-reactive protein (CRP) in patients treated with LPD and inulin (p = 0.018 and p = 0.003, respectively), an improvement in SF-36 (physical role functioning and general health perceptions, p = 0.03 and p = 0.01, respectively), and a significant increase of serum bicarbonate both in patients treated with LPD (p = 0.026) or with LPD and inulin (p = 0.01). Moreover, in patients treated with LPD and inulin, we observed a significant reduction in circulating tumor necrosis factor alpha (TNF-&alpha, ) (p = 0.041) and plasma nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX2) (p = 0.027) levels. We did not find a significant difference in the circulating levels of Interleukin (IL)-1&beta, (p = 0.529) and IL-6 (p = 0.828) in the two groups. Conclusions: LPD, associated or not with inulin, modified gut microbiota and modulated inflammatory and metabolic parameters in patients with CKD. Our results suggest that interventions attempting to modulate the gut microbiome may represent novel strategies to improve clinical outcomes in CKD patients and may provide useful therapeutic effects.

In 1914, Abel, along with Rowentree and Turner, introduced the term “plasmapheresis” whose literal meaning is “subtraction”. The first “therapeutic plasmapheresis” was performed in 1952 in a patient with multiple myeloma; in 1963, patients with paraproteinemia were treated with plasmapheresis to reduce blood hyperviscosity, as described by Salomon and Fahey. During the course of time, more specific and selective techniques were gradually introduced, allowing the use of the treatment for new clinical indications (plasma exchange, CRYO apheresis, leukapheresis, thrombocytopheresis, lymphocyte apheresis, LDL apheresis). The current indications for plasmapheresis have been defined, and periodically re-established, by two scientific American associations, the American Association of Blood Banks (AABB) and the American Society of apheresis (ASFA), based on the available evidence of efficacy of this treatment in specific diseases. In 1993, a study group for therapeutic apheresis was created within the Italian So...

Since its first use apheresis has changed, developing in terms of different materials and techniques, and has been applied to treat several types of diseases. Thus, apheresis has become a complex therapeutical device that requires particular knowledge and expertise.Overall the use of this technique has been poorly managed in Italy, as well as in Europe, since physicians cannot refer to specific guidelines for its application. The purpose of a study group created in 1993 by the Italian Nephrology Society, is to develop such guidelines and protocols with a multidisciplinary approach. This allows different specializations to bring their knowledge together in a collaboration that will not only result in the realization of a common goal, but will also allow to clarify specific aspects of their own specialty. Informed consent is a fundamental act in medicine, as it legitimates every medical action. We suggest using a standard process to obtain the consent in any case requiring apheresis.

Chronic kidney disease (CKD) is a highly prevalent condition in the world. Neurological, psychological, and cognitive disorders, related to CKD, could contribute to the morbidity, mortality, and poor quality of life of these patients. The aim of this study was to assess the neurological, psychological, and cognitive imbalance in patients with CKD on conservative and replacement therapy. Seventy-four clinically stable patients affected by CKD on conservative therapy, replacement therapy (hemodialysis (HD), peritoneal dialysis (PD)), or with kidney transplantation (KT) and 25 healthy controls (HC), matched for age and sex were enrolled. Clinical, laboratory, and instrumental examinations, as renal function, inflammation and mineral metabolism indexes, electroencephalogram (EEG), psychological (MMPI-2, Sat P), and cognitive tests (neuropsychological tests, NPZ5) were carried out. The results showed a significant differences in the absolute and relative power of delta band and relative power of theta band of EEG (P = 0.008, P

Introduction: Mortality in dialysis patients is higher than in the general population, and cardiovascular disease represents the leading cause of death. Hypertension and volume overload are important risk factors for the development of left ventricular hypertrophy (LVH) in hemodialysis (HD) and peritoneal dialysis (PD) patients. Other factors are mainly represented by hyperparathyroidism, vascular calcification, arterial stiffness and inflammation. The aim of this study was to compare blood pressure (BP) and metabolic parameters with cardiovascular changes [cardiothoracic ratio (CTR), aortic arch calcification (AAC) and LV mass index (LVMI)] between PD and HD patients. Materials and Methods: 45 patients (23 HD and 22 PD patients) were enrolled. BP measurements, echocardiography and chest X-ray were performed in each patient to determine the LVMI and to evaluate the CTR and AAC. Inflammatory indexes, intact parathyroid hormone (iPTH) and arterial blood gas analysis were also evaluated. Results: LVMI was higher in PD than HD patients (139 ± 19 vs. 104 ± 22; p = 0.04). In PD patients, a significant correlation between iPTH, C-reactive protein and the presence of LVH was observed (r = 0.70, p = 0.04; r = 0.70, p = 0.03, respectively). The CTR was increased in PD patients as compared to HD patients, while no significant differences in cardiac calcifications were determined. Conclusions: Our data indicate that HD patients present more effective BP control than PD patients. Adequate fluid and metabolic control are necessary to assess the adequacy of BP, which is strongly correlated with the increase in LVMI and with the increased CTR in dialysis patients. PD is a home therapy and allows a better quality of life, but PD patients may present a further increased cardiovascular risk if not adequately monitored. © 2014 S. Karger AG, Basel

Introduction: Most forms of human glomerulonephritis (GN) result from immunologic mechanisms that are mediated by the actions of multiple elements of both the innate and adaptive immune systems, thereby resulting in different clinical manifestations. The treatment of immune-mediated kidney disease is based on steroids and immunosuppressive drugs that interfere with the immune processes. These groups of drugs have led to significant benefits, but severe side effects are still frequent. Monoclonal antibodies directed against molecules of inflammation or several cellular components have emerged in clinical practice. Plasmapheresis and new methods to reduce the risks associated with the procedure with standard therapies may be combined. Moreover new therapeutic options have been proposed, as the use of natural anti-inflammatory cytokines or intracellular signaling reducing inflammation. Materials and Methods: We conducted a systematic review on the pathogenetic mechanisms of glomerulonephritis and their therapies. Results: We analized all RCTs and quasi-RCTs evaluating the current knowledge about pathogenetic mechanisms of glomerulonephritis and related therapy were considered. Conclusion: The pathogenetic mechanisms of glomerulonephritis are complex and strongly influenced by immunogenetic factors. Several clinical trials to identify the best therapeutic options for glomerulonephritis have been conducted, but currently, although significant advancements over the last 10 years have been obtained, important questions are still unanswered. Moreover, we need to consider many and important side effects that have the main therapies for glomerulonephritis. Therefore the development of a web enabled data base to assist nephrologists for the treatment of patients with glomerulonephritis is strongly suggested.

L'aferesi ha conosciuto nel tempo, per evoluzione dei materiali d'uso, diversificazione delle tecniche e possibilità di impiego clinico, un progresso tale da rappresentare un presidio terapeutico complesso che richiede specifiche conoscenze e competenze. In Europa, questa attività clinica è stata gestita in maniera poco attenta, tanto che, a oggi, non si riconoscono specifici ambiti di impiego né settori di utenza. Per tale motivo, nel 1993, si è costituito, in seno alla Società Italiana di Nefrologia, il Grappo di Studio dell'aferesi terapeutica. Infatti, in assenza di una specifica o univoca indicazione terapeutica, si rende necessario l'approccio multidisciplinare, che dovrà approdare alla redazione di Linee Guida condivise e a idonei marker di appropriatezza e di efficacia della terapia. Il consenso informato, espressione della volontà del cittadino malato che autorizza il medico a compiere uno specifico trattamento medico-chirurgico, acquisisce un ruolo fondamentale anche nell'ambito dell'aferesi terapeutica. Il medico non ha il “diritto di curare”, ma solo la “potestà” e la “facoltà” di curare su richiesta del paziente, al di fuori dei casi di emergenza. Pertanto, il consenso non è solamente un obbligo deontologico-contrattuale ma l'atto che legittima il trattamento per ogni singolo paziente. Quindi, suggeriamo un percorso standard per l'acquisizione del consenso nell'ambito dell'aferesi.

Introduction The incidence and spectrum of kidney disease in Human Immunodeficiency Virus-infected patients have been altered by the diffused use of highly active antiretroviral therapy; indeed, acute and chronic kidney disease has emerged as a significant cause of morbidity and mortality among Human Immunodeficiency Virus-infected population. Risk factors associated with kidney disease in such Human Immunodeficiency Virus-infected population include aging, hypertension, diabetes mellitus, co-infection with hepatitis C virus, low CD4 cell count, and high Human Immunodeficiency Virus viral load. The aim of this review was to discuss nephropathies in Human Immunodeficiency Virus-infected patients. Materials and Methods We conduct a review on the actual knowledge of acute and chronic Human Immunodeficiency Virus-associated renal disease, metabolic alterations and related nephropathies, and the side effects of highly active antiretroviral therapy. Results We examined all the randomised controlled trials and quasi-randomised controlled trials that evaluate the current knowledge on acute and chronic HIV and highly active antiretroviral therapy associated renal disease. After quality appraisal, 170 met the inclusion criteria for the review. The studies included in the review were grouped into two areas: nephropathy HIV associated and nephropathy highly active antiretroviral therapy associated. Conclusion Early identification and treatment of kidney disease is imperative for preventing further renal damage in Human Immunodeficiency Virusinfected populations and for instituting appropriate management efficiently. The Infectious Diseases Society of America guidelines recommend urinalysis and estimation of kidney function for all Human Immunodeficiency Virus-infected persons at the time of Human Immunodeficiency Virus diagnosis. Periodic monitoring of albuminuria, tubular parameters such as low-molecularweight proteinuria, and the estimated glomerular filtration rate may be useful for early diagnosis of patients at risk for acute or chronic renal disease.

Since 1960, different classes of immunosuppressive drugs have been used in the post-transplant follow-up. Each is assessed for its effectiveness in preventing rejection but also on the basis of the many side effects induced by prolonged treatment. To reduce these side effects, continuous development of knowledge and medical technology to create cutting-edge therapies in the field is necessary. One of these is extracorporeal photochemotherapy (ECP), an immunomodulatory therapy approved by the United States Food and Drug Administration in 1988 for the treatment of advanced forms of cutaneous T-cell lymphoma. EC P is a useful therapeutic tool for the development of immunomodulation supported by CD8+ clone-specific cytotoxic lymphocytes. The T cells targeted by EC P are modified by photoactivation and seem to develop marked immunogenicity with no suppression of the immune response. Recent studies suggest the possible utility of EC P in the treatment of glomerulonephritis and in countering rejection after transplantation of organs including the kidney.