Vascular calcification progression modulates the risk associated with vascular calcification burden in incident to dialysis patients

Background: It is estimated that chronic kidney disease (CKD) accounts globally for 5 to 10 million deaths annually, mainly due to cardiovascular (CV) diseases. Traditional as well as non-traditional CV risk factors such as vascular calcification are believed to drive this disproportionate risk burden. We aimed to investigate the association of coronary artery calcification (CAC) progression with all-cause mortality in patients new to hemodialysis (HD). Methods: Post hoc analysis of the Independent study (NCT00710788). At study inception and after 12 months of follow-up, 414 patients underwent computed tomography imaging for quantification of CAC via the Agatston methods. The square root method was used to assess CAC progression (CACP), and survival analyses were used to test its association with mortality. Results: Over a median follow-up of 36 months, 106 patients died from all causes. Expired patients were older, more likely to be diabetic or to have experienced an atherosclerotic CV event, and exhibited a significantly greater CAC burden (p = 0.002). Survival analyses confirmed an independent association of CAC burden (hazard ratio: 1.29; 95% confidence interval: 1.17–1.44) and CACP (HR: 5.16; 2.61–10.21) with all-cause mortality. CACP mitigated the risk associated with CAC burden (p = 0.002), and adjustment for calcium-free phosphate binder attenuated the strength of the link between CACP and mortality. Conclusions: CAC burden and CACP predict mortality in incident to dialysis patients. However, CACP reduced the risk associated with baseline CAC, and calcium-free phosphate binders attenuated the association of CACP and outcomes, suggesting that CACP modulation may improve survival in this population. Future endeavors are needed to confirm whether drugs or kidney transplantation may attenuate CACP and improve survival in HD patients

L'eritropoietina e la cardiopatia ischemica: un nuovo attore tra apoptosi e angiogenesi cardiovascolare

L'eritropoietina, per molti anni intesa unicamente come principale regolatore della massa eritrocitaria circolante, ha svelato nel corso degli anni sempre nuove pagine di fisiologia, che l'hanno mostrata come elemento centrale di un complesso sistema che mantiene l'equilibrio tra ossigenazione periferica, stabilità vascolare e stress ossidativo. Al crescere delle conoscenze sulla fisiologia autocrina e paracrina dell'EPO, sono cresciute le aspettative verso l'utilizzo clinico-pratico di tali conoscenze. La presente review propone una rapida carrellata sulle diverse potenziali applicazioni dell'EPO nel management clinico della cardiopatia ischemica, con particolare riguardo alle strategie testate per ottenere gli effetti pleiotropici dell'EPO senza indurre indesiderati incrementi dell'ematocrito

L'ecocardiografia e il Nefrologo: una "Pocket Guide" per Nefrologi Curiosi

Abstract non disponibile (Cardionephrology

Cholesteatoma vs granulation tissue: a differential diagnosis by DWI-MRI apparent diffusion coefficient

To diagnose cholesteatoma when it is not visible through tympanic perforation, imaging techniques are necessary. Recently, the combination of computed tomography and magnetic resonance imaging has proven effective to diagnose middle ear cholesteatoma. In particular, diffusion weighted images have integrated the conventional imaging for the qualitative assessment of cholesteatoma. Accordingly, the aim of this study was to obtain a quantitative analysis of cholesteatoma calculating the apparent diffusion coefficient value. So, we investigated whether it could differentiate cholesteatoma from other inflammatory tissues both in a preoperative and in a postoperative study

Treatment of secondary hyperparathyroidism : the clinical utility of etelcalcetide

Secondary hyperparathyroidism (SHPT), a very frequent, severe, and worsening complication of chronic kidney disease, is characterized by high serum parathyroid hormone (PTH), parathyroid gland hyperplasia, and disturbances in mineral metabolism. Clinically, SHPT shows renal osteodystrophy, vascular calcification, cardiovascular damage, and fatal outcome. Calcium-sensing receptor (CaSR) is the main physiological regulator of PTH secretion; its activation by calcium rapidly inhibits PTH. Another important player in regulating mineral metabolism is vitamin D receptor (VDR), which is under the influence of vitamin D and influences the intestinal absorption of calcium and phosphate, PTH gene expression, and bone calcium mobilization. Serum phosphate levels influence fibroblast growth factor 23 (FGF-23) production, a phosphatonin that modulates serum phosphate reabsorption, PTH synthesis, and vitamin D production. Current therapeutic approaches consist of 1) phosphate intake control by diet or phosphate binders, 2) vitamin D by VDR activation, and 3) calcimimetic agents that activate CaSR. Recently, a new long-acting peptide (etelcalcetide) belonging to the calcimimetics class was approved for intravenous use in hemodialysis patients with SHPT. Etelcalcetide binds directly to CaSR, by a sulfide bond, inhibiting the production and secretion of PTH by parathyroid glands. After intravenous administration in rats, etelcalcetide is quickly distributed to the tissues and eliminated by kidneys, while in uremic animals the nonrenal excretion is only 1.2%. In hemodialysis patients, the treatment itself is the main route of elimination. Etelcalcetide in hemodialysis patients with SHPT was more effective than placebo and cinacalcet, with a PTH reduction of >30% in 76% of patients with etelcalcetide versus 10% with placebo. Particular attention was paid to the safety of the drug; the most common adverse event was asymptomatic blood calcium reduction, similar to cinacalcet, while gastrointestinal symptoms were less frequent. This promising new drug available for better control of SHPT will, together with drugs already in use, optimize the treatment to normalize the biochemical parameters

Quadro severo di mieloma multiplo e insufficienza renale trattato con successo con bortezomib e desametasone

Il trattamento delle malattie mieloproliferative richiede sempre più frequentemente il coinvolgimento della figura del nefrologo nella gestione terapeutica. Il nefrologo è chiamato a mettere in atto una serie di provvedimenti terapeutici che mirino a correggere fattori precipitanti la funzionalità renale. Mostreremo un caso emblematico di gestione ematologica e nefrologica di un caso di mieloma multiplo di tipo micromolecolare con severa compromissione renale trattato con successo con associazione di Velcade e desametasone in 8 cicli in un periodo di 6 mesi. In questo periodo il paziente è stato supportato con terapia medica e infusionale per mantenere un'adeguata idratazione, una costante alcalinizzazione delle urine, buoni livelli di albuminemia, calcemia e uricemia senza ricorrere a trattamento dialitico sostitutivo. Non viene mai sospeso il trattamento chemioterapico e gli effetti tossici più importanti vengono monitorati e trattati con terapia specifica senza mai ridurre il dosaggio del chemioterapico. Si ottiene un progressivo recupero della funzione renale oltre a una remissione della malattia di base

Thromboembolic and bleeding risk in atrial fibrillation patients with chronic kidney disease: role of anticoagulation therapy

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients

Single-center open-label randomized study of anemia management improvement in ESRD patients with secondary hyperparathyroidism

Whether anemia and mineral bone abnormalities (chronic kidney disease\u2013mineral bone disorder [CKD-MBD]) are associated still remains to be elucidated. Both anemia and CKD-MBD have been associated with adverse cardiovascular outcome and poor quality of life. However, recent evidence suggests that use of large doses of erythropoietin-stimulating agents (ESAs) to correct hemoglobin (Hb) may be detrimental in CKD. The Optimal Anemia Treatment in End Stage Renal Disease (ESRD) (Optimal ESRD Treatment) study will assess whether lowering of parathyroid hormone (PTH) is associated with a reduction in ESA consumption. The Optimal ESRD Treatment study is a pilot single-center open-label study with blinded end point (a prospective randomized open blinded end-point [PROBE] design) enrolling 50 patients on maintenance dialysis. Eligible patients with intact PTH (iPTH) 300-540 pg/mL and Hb 10-11.5 g/dL will be randomized 1:1 to strict PTH control (150-300 pg/mL) versus standard care (PTH range 300-540 pg/mL). Available drugs for CKD-MBD and anemia treatment will be managed by the attending physician to maintain the desired levels of PTH (according to study arm allocation) and Hb (10-11.5 g/dL). Echocardiographic data for cardiac structure and function as well as arterial stiffness will be assessed at study inception and completion. The Optimal ESRD Treatment study should shed light on the complicated interplay of anemia and CKD-MBD and on the feasibility of clinical trials in this domain. The study results are expected in the spring of 2017

Ivabradine, heart failure and chronic kidney disease

The incidence and prevalence of congestive heart failure are actually increasing worldwide, especially inWestern countries. In Europe and the United States, congestive heart failure represents a disabling clinical disease, accountable for increased hospitalization and health care costs. European guidelines have underlined the importance of pharmacological treatment to improve both patients\u2019 outcomes and quality of life. The latest clinical trials to evaluate ivabradine\u2019s efficacy have underlined its usefulness as a stand-alone medication and in combination with conventional congestive heart failure therapy, including in chronic kidney disease patients