Posizionamento ecoguidato di cateteri venosi centrali

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Phosphate overload accelerates vascular aging in uremic patients

Vascular calcification is a very common event in atients affected by diabetes and chronic kidney disease (CKD). Recently, it has been well documented that abnormalities in mineral and bone metabolism in CKD patients are associated with increased morbidity and mortality. Elevated serum phosphate and calcium-phosphate product levels play an important role in the pathogenesis of vascular mineralization in uremic patients and also appear to be associated with increased cardiovascular mortality. Together with classical passive precipitation of calcium-phosphate in soft tissues, during the last decade it has been demonstrated that inorganic phosphate may cause extraskeletal calcification directly through a real “ossification” of the tunica media in the vasculature of CKD patients. Therefore, control of phosphate retention is now an even more crucial target of treatment in patients affected by chronic kidney disease

Vitamin D Receptor Activators and Clinical Outcomes in Chronic Kidney Disease

Vitamin D deficiency appears to be an underestimated risk factor for cardiovascular disease in patients with chronic kidney disease. Evidence from both basic science and clinical studies supports the possible protective role of vitamin D beyond its effect on mineral metabolism. Toxicity of pharmacologic doses of active vitamin D metabolites, in particular calcitriol, is mainly due to the possibility of positive calcium and phosphorus balance. Therefore, vitamin D analogs have been developed, which suppress PTH secretion and synthesis with reduced calcemic and phosphatemic effects. Observational studies suggest that in hemodialysis patients the use of a vitamin D receptor (VDR) activator, such as calcitriol, doxercalciferol, paricalcitol, or alfacalcidol, is associated with a reduced mortality when compared with nonusers of any VDR activator. In this article the existing literature on the topic is reviewed, although a more robust answer to the question of whether or not VDR activators have beneficial effects in hemodialysis patients will hopefully come from a randomized controlled trial

Proteinuria in pregnancy: Clinically driven considerations:

Introduction: Proteinuria assessment is a key test in pregnancy to evaluate renal and systemic well-being. The finding of proteinuria may allow diagnosis and ready intervention for pre-eclampsia and glomerulonephritis, which may compromise a favorable delivery. Moreover, pathological-range isolated proteinuria is a risk factor by itself for adverse outcomes during pregnancy. An appropriate interpretation of pathologic values of proteinuria is therefore of crucial importance. Patient presentation: We present the case of a 33-year-old apparently healthy woman at her first pregnancy who developed a clinically significant proteinuria during the first trimester; we describe the clinical workup and the management of the patient up to delivery. Conclusion: Urine analysis with dipstick or protein-to-creatinine ratio is part of the routine prenatal clinical care during pregnancy. Detection of a pathological proteinuria (>300 mg/24 h or equivalent) should never be underestimated, and timed urine collection is required, as well as a thorough medical examination. The main goal is to exclude pre-eclampsia, whereas the suspect of a primary kidney disease can be managed together with the nephrologist, both for management and treatment

Multicenter Experience with the Surfacer Inside-Out Access Catheter System in Patients with Thoracic Venous Obstruction: Results from the SAVE Registry.

ABSTRACT Purpose To report device performance and safety for the Surfacer® Inside-Out® access catheter system in patients with thoracic central venous obstruction (TCVO) requiring central venous access (CVA). Materials and Methods Five sites prospectively enrolled 30 patients requiring a tunneled dialysis catheter between February 2017 and September 2018 in the Surfacer System to Facilitate Access in Venous Obstructions (SAVE) Registry (NCT02875899). Patient demographics, medical history and type of TCVO were documented at enrollment. Device performance and adverse events were collected during the procedure and upon hospital discharge. Twenty-nine of the 30 patients enrolled required CVA for hemodialysis. Retrospective classification of TCVOs according to SIR Reporting Standards showed 9 patients (30%) had Type 4 obstructions, 8 (26.7%) had Type 3, 5 (16.7%) had Type 2 and 8 (26.7%) had Type 1 obstructions. Results Central venous cathters (CVCs) were successfully placed in 29 of 30 patients (96.7%). The procedure was discontinued in one patient due to vascular anatomical tortuosity. All 29 patients with successful CVC placement achieved adequate catheter patency and tip positioning. There were no device-related adverse events, catheter malposition, intra- or postprocedural complications. Mean time from device insertion to removal for the 29 patients who successfully completed the procedure was 24±14.9 (range 6 to 70) minutes. Mean fluoroscopy time was 6.8±4.5 (range 2.2 to 25.5) minutes. Conclusion The Surfacer Inside-Out procedure provides an alternative option to restore right-sided central venous access in patients with TCVO

Il trattamento dell'iperparatiroidismo secondario con gli analoghi della vitamina D:

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ASSOCIATION OF CALCIFEDIOL LEVELS WITH VERTEBRAL FRACTURES, VASCULAR CALCIFICATIONS AND MORTALITY.

The best biomarker of Vitamin D status is calcifediol [25(OH)D]. We investigated the relationship between serum calcifediol levels and vertebral fractures (VF), vascular calcifications (VC) and mortality in hemodialysis patients. Within a multicenter, cross-sectional study in 18 hospital based dialysis centers in Italy, we included 387 hemodialysis patients (143 F, 37% ; 244 M, 63%), mean age 64±14 (SD) years, median dialytic age 49 months, BMI 25± 4 Kg/m2. We determined total 25(OH)D using the LIASON® 25 OH Vitamin D kit (DiaSorin Inc., Stillwater MN, USA). We evaluated VF with a computerized analysis of scanned L-L vertebral X-rays (T4 to L5). Reduction of > 20% of vertebral body height was considered a VF, while reductions between 15% and 20% were considered borderline fractures (BF). Fracture severity was estimated as mild, moderate or severe (reduction: 20–25%, 25–40% or >40%, respectively). VC assessments were also centralized. Witteman's method (Lancet, 1994) was used for blinded assessments in duplicate. VC were quantified by measuring the length of calcific deposits along the anterior and posterior wall of the aorta (mild 0.1-5 cm, moderate 5.1-10 cm and severe >10 cm). We also evaluated the presence or absence of calcifications of the iliac arteries in the same radiograph (mild 0.1-3 cm, moderate 3.1-5 cm and severe >5cm). Any differences in VC were resolved by consensus. Follow up was 2.7±0.5 years. Bone markers were: Ca 9.15±0.68 mg/dl, P 4.8± 1.28 mg/dl, median ALP 83 U/L and median PTH 244 pg/ml. We found a median 25(OH)D level of 28.9 ng/ml. Nine ( 2.3%) patients had vitamin D deficiency (30 ng/ml). We found that 55% of patients had VF and 30.9% of patients had BF. Prevalence of VC was 80.6% (mild 20.1%, moderate 30.8%, severe 29.7%) in the aorta and 55,1% in the iliac arteries. Males had more VF than Females (60% versus 48%, P=0.019). No associations were found between VF and biochemical parameters including calcifediol levels (p=0.662), while we found an association between low calcifediol levels and a higher prevalence of severe aortic calcifications (36.8 vs 28.2, p=0.0044). Furthermore, we found a OR 1.85 (1.04-3.29 CI, p=0.0367) for Aortic Calcification in patients with calcifediol levels lower than the median value of 29 ng/ml. During follow-up (2.7±0.5 years) mortality was of 19.9%. No association was found between mortality and calcifediol levels (p=0.5394). In conclusion, despite good control of bone and mineral metabolism parameters, hemodialysis patients showed high prevalence of VF and VC. Our study suggests that high calcifediol levels could be protective against progression of severe aortic calcificatio

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

A Complex Renal Cyst: It Is Time to Call the Oncologist?

Introduction. Hydatid disease is a cyclozoonotic parasitic infestation caused by the cestode Echinococcus granulosus. The cysts mainly arise in the liver (50 to 70%) or lung (20 to 30%), but any other organ can be involved, in abdominal and pelvic locations, as well as in other less common sites, which may make both diagnosis and treatment more complex. Isolated renal involvement is extremely rare. Case Presentation. We report a rare case of isolated renal hydatid disease in a 71-year-old man with a history of vague abdominal pain, anemia, fever, and microhematuria. Ultrasonographic examination revealed a complex cyst in the right kidney, including multiple smaller cysts with internal echoes. A magnetic resonance scan of the abdomen confirmed the findings, and hydatid cyst disease was diagnosed. Right nephrectomy was performed, and microscopic examination confirmed the diagnosis of hydatid cyst. Albendazole, 10 mg/kg per day, was given for 4 weeks (2 weeks preoperatively and 2 weeks postoperatively). Conclusion. Isolated primary hydatidosis of the kidney should always be considered in the differential diagnosis of any cystic renal mass, even in the absence of accompanying involvement of liver or other visceral organs

Индекс стабилизации Фабри (FASTEX): инновационный инструмент для оценки клинической стабилизации при болезни Фабри

На сегодняшний день предложены 2 системы количественной оценки бремени гликогеноза с дефицитом α-галактозидазы: индекс оценки степени тяжести Майнца (MSSI) и система балльной оценки тяжести болезни Фабри (DS3). Сделана попытка разработать динамическую математическую модель FASTEX (от англ. FAbry STabilization indEX, индекс стабилизации Фабри) для оценки клинической стабильности состояния. Мультидисциплинарная группа экспертов по болезни Фабри впервые предложила новую шкалу оценки тяжести заболевания по предварительной оценке (от англ. raw score, RS), основанную на 3 доменах (домен нервной системы (боль, цереброваскулярные события), почечный домен (протеинурия, скорость клубочковой фильтрации), сердечный домен (параметры эхокардиографии, электрокардиографии и степень сердечной недостаточности по классификации Нью-Йоркской кардиологической ассоциации)) с небольшим числом пунктов в каждом из них и оценкой клинической стабильности во времени. RS протестирована на 28 пациентах (15 мужчин и 13 женщин) с классической формой болезни Фабри. Получена сильная корреляционная связь предложенной оценки RS и взвешенной оценки (от англ. weighted score, WS) с DS3 и MSSI (r2 = 0,914; 0,949; 0,910 и 0,938 соответственно). Для уточнения RS была рассчитана WS, выражаемая в процентах. WS была основана на относительной клинической значимости каждого пункта в пределах домена, при этом группа экспертов согласовывала присвоение разного веса клинического вреда конкретной системе органов. Для определения динамики тяжести заболевания RS была повторно определена через 1 год. Группа экспертов согласилась с пороговым ограничением в 20 % от исходного уровня в качестве клинической WS для определения клинической стабильности. Модель FASTEX показала хорошую корреляцию с клинической оценкой и клиническим изменением на протяжении времени у всех пациентов.