Dietary fiber and gut microbiota in renal diets

Nutrition is crucial for the management of patients affected by chronic kidney disease (CKD) to slow down disease progression and to correct symptoms. The mainstay of the nutritional approach to renal patients is protein restriction coupled with adequate energy supply to prevent malnutrition. However, other aspects of renal diets, including fiber content, can be beneficial. This paper summarizes the latest literature on the role of different types of dietary fiber in CKD, with special attention to gut microbiota and the potential protective role of renal diets. Fibers have been identified based on aqueous solubility, but other features, such as viscosity, fermentability, and bulking effect in the colon should be considered. A proper amount of fiber should be recommended not only in the general population but also in CKD patients, to achieve an adequate composition and metabolism of gut microbiota and to reduce the risks connected with obesity, diabetes, and dyslipidemia

Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication

The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an "option" in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management

Lupus nephritis and B-cell targeting therapy

Lupus\ua0Nephritis (LN) is a severe manifestation of Systemic Lupus Erythematosus (SLE) with a significant prognostic impact. Over a prolonged course, an exhaustion of treatment alternatives may occur and further therapeutic options are needed. B cells play a pivotal role in disease pathogenesis and represent an attractive therapeutic target. Areas covered: This review provides an update regarding targeting B cells in LN. The rational for this approach, as well as currently available and future targets are discussed. Expert commentary: Despite its wide clinical use and the encouraging results from retrospective studies, a role of rituximab in LN has not been prospectively confirmed. Trial design methodologies as well as intrinsic limitations of this approach may be responsible and rituximab use is currently limited as a rescue treatment or in settings where a strong steroid sparing effect is warranted. Despite belimumab now being licensed for use in SLE, the evidence in LN is weak although prospective trials are on-going. The combination of different targeted approaches as well as a focus on new clinical end-points may be strategies to identify new therapeutic options

Pathogenesis of secondary hyperparathyroidism

Chronic renal failure is the primary cause of secondary hyperparathyroidism (SHPT). Patients with mineral metabolism disorders commonly present with low serum calcium levels, hyperphosphatemia, and calcitriol deficiency. In normal renal function subjects, parathyroid cells have a low turnover and rarely undergo mitoses. In uremic conditions, however, parathyroid glands become hyperplasic and leave quiescence. During the last ten years, new molecular mechanisms have been investigated to better understand the pathogenesis of SHPT: the emerging role of the Calcium Sensing Receptor (CaSR); the importance of the parathyroid expression of the Vitamin D receptor (VDR); the growing evidence on the central role of the Fibroblast Growth Factor 23 (FGF-23). In contrast, the discovery of a parathyroid phosphate sensor or receptor has yet to be made

Urinary N-acetyl-β-glucosaminidase and eGFR may identify patients to be treated with immuno-suppression at diagnosis in idiopathic membranous nephropathy

Background The clinical course of idiopathic membranous nephropathy (IMN) varies from spontaneous remission of nephrotic syndrome (NS) to end-stage renal disease (ESRD). Selecting patients with high risk of progression for immunosuppressive therapy is mandatory. Methods 86 IMN subjects were followed for median of 69\u2009months (range 6-253). Receiver operating characteristic curve and Cox proportional hazards model were used to evaluate prognostic factors for progression, defined as ESRD or eGFR reduction 6550% of baseline. Results Among all, 24 subjects had progression. Area under the ROC curve of N-acetyl-\u3b2-glucosaminidase/creatinine ratio (NAG/C) were significantly higher than proteinuria/24\u2009h (0.770 and 0.637 respectively, p\u2009=\u20090.018). In Cox proportional hazards regression analysis, NAG/C and eGFR were independent predictors of progression. Compared to lowest tertile of NAG/C (<9.4 UI/gC) or highest tertile of eGFR ( 6588\u2009ml/min/1.73\u2009m2), the multivariable-adjusted hazard ratio of highest tertile of NAG/C ( 6519.2) was 18.97 (95%CI, 1.70-211.86) and lowest tertile of eGFR (<59) was 11.58 (95%CI, 2.02-66.29). Subjects with high NAG/C or low eGFR (high-risk, n\u2009=\u200943) had greater progression rate compared to moderate to low NAG/C and high eGFR (low-risk, n\u2009=\u200943) with or without NS at baseline (Log-rank test p\u2009=\u20090.001 and 0.006, respectively). In NS subjects (n\u2009=\u200965), high-risk group progression rate was significantly higher (91% vs. 29%, p\u2009=\u20090.003) and remission rate significantly lower (0% vs. 42%, p\u2009<\u20090.001) in non-immunosuppressed compared to steroids and cyclophosphamide treated patients; no significant differences were observed in low-risk group. Conclusion IMN subjects with high NAG/C and low eGFR have greater risk of progression, and immunosuppressive treatment is suggested at diagnosis

Iperfosfatemia in dialisi: la scelta del chelante

Le linee guida KDIGO del 2017 confermano le indicazioni delle precedenti sulla necessit\ue0 di mantenere i livelli sierici di fosforo nei pazienti in dialisi quanto pi\uf9 possibile vicino alle concentrazioni normali dello ione. Questi suggerimenti nascono da numerosi studi che hanno evidenziato sia una stretta associazione tra livelli di fosforemia ed eventi fatali e non fatali sia che circa il 30% dei pazienti emodializzati presenta livelli sierici elevati di fosforo. Le stesse linee guida KDIGO forniscono indicazioni terapeutiche sul controllo della iperfosforemia, sottolineando l\u2019importanza sia della nutrizione sia dell\u2019opportuna prescrizione dei chelanti del fosforo in considerazione del parziale controllo della iperfosforemia ottenibile mediante le tecniche dialitiche. Il chelante \u201cideale\u201d tuttora non esiste; tuttavia l\u2019 ampia disponibilit\ue0 di chelanti del fosforo consente di ottenere una terapia personalizzata cio\ue8 funzionale al singolo paziente. Questo contribuisce ad ottenere sia un miglior controllo della fosforemia con minori effetti collaterali sia di incrementare la aderenza (compliance) del paziente alla terapia chelante. La quantit\ue0 di pillole prescritta dal medico al paziente \ue8 inversamente correlata all\u2019aderenza terapeutica del paziente stesso. A rendere questo problema particolarmente importante \ue8 il peso enorme che ha la terapia chelante il fosforo sul carico di compresse assunto ogni giorno dai pazienti dializzati. Negli ultimi anni \ue8 disponibile un chelante non contenente calcio l\u2019ossidrossido sucroferrico, il cui potere legante il fosforo \ue8 molto elevato per cui si rende necessario prescrivere un numero limitato di pillole. Questa caratteristica dell\u2019ossidrossido sucroferrico \ue8 stata confermata dagli studi controllati e randomizzati finora disponibili. L\u2019ossidrossido sucroferrico pu\uf2 rappresentare una alternativa terapeutica, in monoterapia e in associazione, nel trattamento dell\u2019iperfosforemia. Studi sono in corso per verificare nella \u201creal life\u201d la incidenza di effetti collaterali gastroenterici evidenziati con l\u2019ossidrossido sucroferrico.Several studies have evidenced the association between high serum phosphorus concentrations and adverse events especially in patients on dialysis. Recent K-DIGO guidelines suggest lowering elevated phosphate levels toward the normal range. This goal should be achieved by combining dietary counseling, optimizing dialysis procedures and prescribing phosphate binders. Despite the availability of several binders, the "ideal" phosphate binder that combines high efficacy, low pills burden, minimal side effects and low cost is still not available. In clinical practice it is crucial to reach a high patient's compliance to therapy. The pill burden is the most relevant factor contributing to low compliance. This is the case of phosphate binder therapy that represents almost 50% of total pills prescribed to patients on dialysis. It has been evidenced an association between pills of phosphate binder and poor control of phosphorus and PTH. In recent years sucroferric oxyhydroxide is available as a new phosphate binder. Its peculiarity is an high phosphate binding capability that requires prescription of low number of pills per day. This characteristic has been confirmed by several randomized controlled trials. These trials have also evidenced that sucroferric oxyhydroxide may cause some gastrointestinal side effects. There is an ongoing study to confirm in "the real world" the incidence of side effects reported by controlled trials

GECO: a prototype broadband triaxial seismic sensor with on board digital electronics

The prototype of a broadband triaxial seismic sensor (GECO) developed at the Department of Astronomy and Space Science of the University of Florence (Italy) is presented. The three sensor axes, based on an inverted pendulum, are placed in a corner cube configuration. A “C” shaped leaf spring is used in order to compensate gravity and the output signal of a capacitive position sensor is force balanced by a feedback system. The sensor integrates on-board digital electronics with 24 bits resolution, flash memory for data storage capability, and a GPS interface. The sensor has been tested against a commercial broadband sensor: amplitude and spectral analyses of seismic ambient noise and local, regional and teleseismic earthquakes have been performed in order to compare the response of the prototype with the used reference. The prototype was found to be compatible with the reference seismometer both in amplitude and frequency showing its capability to resolve lowfrequency and low-amplitude signals

Opening an onconephrology clinic: Recommendations and basic requirements

Onconephrology is a rapidly evolving subspeciality that covers all areas of renal involvement in cancer patients. The complexity of the field may benefit from well-defined multidisciplinary management administered by a dedicated team. Since there is an increasing need to address the needs of this population in dedicated outpatient clinics, it is critical to highlight basic characteristics and to suggest areas of development. In this brief perspective article, we analyse the requirements of an onconephrology clinic in terms of logistics, critical mass of patients and building a multidisciplinary team. We will further discuss which patients to refer and which conditions to treat. The last part of the article is dedicated to education and performance indicators and to analysis of the potential advantages of applying the hub-and-spoke model to this field. The ultimate aim of this experience-based article is to initiate debate about what an onconephrology outpatient clinic might look like in order to ensure the highest quality of care for this growing population of patients