Patients' wishes, pregnancy and vascular access: When one size does not fit all

Pregnancy in dialysis patients is a rare but important event that challenges our knowledge and demands re-thinking many aspects of our practice, including vascular access. This editorial briefly discusses some open questions on vascular access in this situation that challenge the motto ‘fistula first’ and underline the need for personalised approaches. Information on vascular access in pregnant women is scant. Different approaches may be considered between women on dialysis already on a well-functioning tunnelled catheter and newly placed catheters: while a tunnelled catheter in a woman already stabilised on outpatient dialysis, who has shown being able to take correct care of it and who has freely chosen this option, is a reasonable choice, central venous catheters placed during pregnancy, especially in the hospital setting, may have a high risk of complications. Conversely, pregnancy may increase the risk of development of fistula aneurysms, but the frequency of this complication is still unknown. The problem of whether or not shifting pregnant patients on peritoneal dialysis to daily haemodialysis sessions is still open, as well as the role of patients’ preference for avoidance of an invasive procedure, or refuse of pain. In the wait for answers, reflecting on the problems encountered by pregnant women on dialysis should make us reflect on how to improve vascular access management for all our patients

Charcoal for the management of pruritus and uremic toxins in patients with chronic kidney disease

Purpose of review: Pruritus is an important, prevalent but often neglected symptom in patients with advanced chronic kidney disease (CKD) or on dialysis. This review addresses the use of activated charcoal and its analogs in the treatment of uremic pruritus, which can be a sign of uremic toxicity. Recent findings: When common causes are corrected and dialysis efficiency is optimized, pruritus is mainly ascribed to the retention of middle and protein-bound molecules, of which indoxyl sulfate and p-cresyl sulfate are the best studied. While hemodialysis and hemodiafiltration are of limited use, activated charcoal and its analogs offer interesting alternatives. Oral preparations are associated with symptom improvement and a better metabolic pattern, probably via a combination of absorption and modification of the intestinal microbiota. Large studies, in well phenotyped populations, are needed. Hemoperfusion, commonly used in poisoning and intoxication, could be an interesting alternative in hemodialysis patients. The treatment has proved promising in some preliminary and small studies; more research is now needed to test its validity. Summary: Oral activated charcoal and hemoperfusion can be proposed to patients with severe refractory pruritus based on positive, albeit scattered evidence. They also contribute to reducing uremic toxins. Research on their implementation associated with well established treatments is needed to understand whether they can be used as 'uremic detoxifiers'

Onco-nephrology : a decalogue

Onco-nephrology is an evolving subspecialty that focuses on the complex relationships existing between kidney and cancer. In this opinion piece, we propose a 'decalogue of onco-nephrology', in order to highlight the areas where the nephrologist and oncologist should work closely over the ensuing years to provide cutting-edge care for patients afflicted with cancer and kidney disease. The 10 points we have highlighted include (1) acute kidney injury and chronic kidney disease in cancer patients; (2) nephrotoxic effects of anticancer therapy, either traditional chemotherapeutics or novel molecularly targeted agents; (3) paraneoplastic renal manifestations; (4) management of patients nephrectomized for a kidney cancer; (5) renal replacement therapy and active oncological treatments; (6) kidney transplantation in cancer survivors and cancer risk in ESRD patients; (7) oncological treatment in kidney transplant patients; (8) pain management in patients with cancer and kidney disease, (9) development of integrated guidelines for onco-nephrology patients and (10) clinical trials designed specifically for onco-nephrology. Following these points, a multidisciplinary onco-nephrology team will be key to providing outstanding, cutting-edge care in both the acute and chronic setting to these patients

Onco-nephrology: A decalogue

Onco-nephrology is an evolving subspecialty that focuses on the complex relationships existing between kidney and cancer. In this opinion piece, we propose a 'decalogue of onco-nephrology', in order to highlight the areas where the nephrologist and oncologist should work closely over the ensuing years to provide cutting-edge care for patients afflicted with cancer and kidney disease. The 10 points we have highlighted include (1) acute kidney injury and chronic kidney disease in cancer patients; (2) nephrotoxic effects of anticancer therapy, either traditional chemotherapeutics or novel molecularly targeted agents; (3) paraneoplastic renal manifestations; (4) management of patients nephrectomized for a kidney cancer; (5) renal replacement therapy and active oncological treatments; (6) kidney transplantation in cancer survivors and cancer risk in ESRD patients; (7) oncological treatment in kidney transplant patients; (8) pain management in patients with cancer and kidney disease, (9) development of integrated guidelines for onco-nephrology patients and (10) clinical trials designed specifically for onco-nephrology. Following these points, a multidisciplinary onco-nephrology team will be key to providing outstanding, cutting-edge care in both the acute and chronic setting to these patients

Vitamin K effects in human health: new insights beyond bone and cardiovascular health

Vitamin K is a cofactor for the function of the enzyme \u3b3-glutamyl carboxylase, necessary for the activation of multiple vitamin K dependent-proteins. Vitamin K dependent-proteins (VKDPs) have important roles in bone health, vascular health, metabolism, reproduction as well as in cancer progression. Vitamin K deficiency is common in different conditions, including kidney disease, and it may influence the activity of VKDPs. This review discusses vitamin K status in human health and the physiologic and pathologic roles of VKDPs, beyond the established effects in skeletal and cardiovascular health

Uso degli anticoagulanti orali per la prevenzione della trombosi dei cateteri venosi centrali per emodialisi

Central venous catheters (CVCs) are fundamental in the management of hemodialysis. Despite major efforts to provide arteriovenous access, their use is increasing in dialysis units worldwide. The presence of a catheter inside a vein increases the risk of thrombosis, both within the catheter and in the vein. Thrombosis is a serious complication because it can lead to inefficient dialysis, alter the venous circulation, and facilitate infections. In this article, questions regarding anticoagulant treatment in dialysis patients with CVCs are explored and specific suggestions offered for clinical practice, based on the evidence available and the personal experience of the authors. Should CVC-induced thrombosis be treated? The duration, site and extension of the thrombotic complication should be assessed. If thrombosis is recent and symptomatic, heparin treatment followed by oral anticoagulant therapy is suggested. Is oral anticoagulant therapy useful for primary prevention of thrombosis, both within the CVC and the vein where the catheter is inserted? The available evidence favoring the use of oral anticoagulant therapy is not entirely convincing. At any rate, before such treatment is started the balance between the antithrombotic efficacy and the possible side effects should be carefully weighed. Is oral anticoagulant therapy useful for secondary prevention of CVC thrombosis? If a permanent CVC is in place and its position is correct and the blood flow < 250 mL/min, we recommend - before replacing the CVC - thrombolytic treatment followed by oral anticoagulants, aiming at an INR target between 2 and 3. Are the side effects of oral anticoagulant therapy an issue? The use of anticoagulants in renal failure carries an increased risk of complications, in particular bleeding and vascular calcifications, which could annul the advantages derived from reduced thrombotic events. Before starting oral anticoagulant therapy we suggest to carefully evaluate if there are potential overall benefits and to pay attention to concomitant antiplatelet therapy

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