Nutrizione e Attività Fisica nei pazienti portatori di trapianto renale.

Basi razionali e Motivazioni dello Studio: Per migliorare l’evoluzione del trapianto e la sopravvivenza del paziente è necessario il controllo delle alterazioni metaboliche e nutrizionali associate al trapianto stesso. In nefrologia, il ruolo prognostico dello stato di nutrizione e dei livelli di attività fisica è stato molto studiato nei pazienti con IRT in trattamento dialitico cronico e, più di recente, nelle fasi iniziali della malattia in terapia conservativa. Nel paziente portatore di trapianto renale (RTR), invece, nonostante i numerosi fattori che vi possano influire, mancano informazioni sistematiche sullo stato di nutrizione, su quale sia il livello dell’attività fisica nel trapianto renale e quali ne siano i determinanti. Garantire un fabbisogno adeguato dei vari nutrienti, contenere l'incremento di peso ed evitare la perdita di massa grassa è importante in ogni individuo; lo è ancora di più nel caso di un paziente RTR che, per la storia clinica e le terapie farmacologiche può essere a rischio di malnutrizione. L’attività fisica svolge un ruolo fondamentale perché è in grado di migliorare il controllo di diabete mellito, ipertensione arteriosa, resistenza insulinica, obesità, dislipidemia e sindrome metabolica ed è, inoltre, essa stessa fattore diretto di “protezione” cardiovascolare (CV). Attese dello Studio: Lo studio si propone di valutare lo stato di nutrizione e la composizione corporea in una coorte di pazienti RTR e, al contempo, di valutare il livello di attività fisica e la sua relazione con le alterazione metaboliche e nutrizionali, identificando anche i possibili fattori determinanti della ridotta attività fisica per realizzare programmi di esercizio fisico adatti per specifiche categorie di pazienti trapiantati, per prevenire le complicanze CV. Metodologia dello Studio: Lo studio è un'osservazione trasversale rivolta a pazienti RTR da almeno 6 mesi, adulti, di entrambi i sessi, che vengono messi a confronto con un gruppo di controllo. Per ogni paziente è stata effettuata una valutazione dello stato nutrizionale (test di screening nutrizionale e misure antropo-plicometriche), della composizione corporea (test strumentali e clinici) e degli introiti alimentari (diari alimentari; recall). Verrà poi valutato lo stato funzionale globale del paziente e, più in particolare, la funzionalità muscolare (misura della forza di presa della mano) e il livello di attività fisica e dispendio energetico (SenseWear Armband). Tutte queste misure verranno incrociate con una valutazione soggettiva della qualità di vita del paziente (questionari) e dello stato di comorbidità. Risultati: I pazienti RTR hanno ridotti livelli di attività fisica, per lo più in durata ma anche per intensità, soprattutto nelle femmine; la forza muscolare risulta significativamente ridotta nei maschi trapiantati. L'intensità dell'attività fisica correla con gli introiti nutrizionali e la composizione corporea. Nonostante la ridotta attività fisica, i pazienti RTR hanno una percezione soggettiva di attività fisica adeguata. Per i pazienti RTR, i valori medi di circonferenza vita risultano al di sotto dei valori di rischio per malattia CV; la circonferenza dei fianchi (indicatore di adiposità sottocutanea) invece risulta lievemente superiore nei controlli. Gli apporti nutrizionali nei trapiantati sono risultati bilanciati e sovrapponibili con i controlli e in linea con le raccomandazioni (LARN) per soggetti sani. Conclusioni: Ad oggi, sulla base delle evidenze fornite dalla letteratura esistente è ragionevole e utile raccomandare un regolare esercizio fisico unito ad una corretta alimentazione ai soggetti RTR. Questo contribuirà al miglioramento della qualità di vita, oltre a ridurre il rischio di malattie CV

Nutrition and Physical Activity in CKD patients

Chronic kidney disease (CKD) patients are at risk for protein-energy wasting, abnormal body composition and impaired physical capacity. These complications lead to increased risk of hospitalization, morbidity and mortality.In CKD patient as well as in healthy people, there is a close association between nutrition and physical activity. Namely, inadequate nutrient (energy) intake impairs physical performance thus favoring a sedentary lifestyle: this further contributes to loss of muscle strength and mass, which limit the quality of life and rehabilitation of CKD patients. In CKD as well as in end-stage-renal-disease patients, regular physical activity coupled with adequate energy and protein intake counteracts protein-energy wasting and related comorbidity and mortality. In summary, exercise training can positively influence nutritional status and the perception of well-being of CKD patients and may facilitate the anabolic effects of nutritional interventions

L'attività fisica in dialisi peritoneale: le opinioni dei nefrologi

In occasione del XVII convegno nazionale del Gruppo di Studio SIN "Dialisi Peritoneale", svoltosi a Montecatini Terme (20–22 Marzo 2014), è stato distribuito un questionario a 141 medici con l'intento di rilevare le opinioni dei nefrologi italiani sulla problematica dell'attività fisica nei pazienti in dialisi peritoneale, e sulle "barriere" che ne impediscono lo sviluppo. La totalità del campione intervistato concorda sull'utilità dell'esercizio fisico e sulla necessità di incrementarlo nella popolazione dialitica. Il 90% degli intervistati reputa che l'attività fisica sia un'importante problematica clinica, e il 78% riesce a trovare il tempo per informarsi riguardo le abitudini del paziente in merito all'esercizio. La maggioranza degli intervistati (61%) ritiene il paziente interessato e, se opportunamente stimolato, disposto ad incrementare l'esercizio fisico (64%). Tuttavia, nonostante le preoccupazioni in merito alla sicurezza dell'attività fisica in dialisi (85%), non tutti si considerano capaci di effettuare una prescrizione in merito (78%). L'86% degli intervistati riferisce di fornire consigli in merito all'attività fisica ma di fornire solo raramente materiale informativo scritto (7%), consigliare al paziente specialisti del settore, e quasi mai di consegnare attrezzature atte a svolgere l'attività fisica indicata (3%). In conclusione, mentre traspare l'interesse a contrastare la sedentarietà e favorire l'attività fisica nei pazienti in dialisi peritoneale, la reale implementazione appare difficile e problematica. È quindi auspicabile una collaborazione scientifica e applicativa che coinvolga più gruppi di studio e più figure professionali dedicate allo sviluppo dell'attività ed esercizio fisico in dialisi peritoneale

Robotic rectal surgery: State of the art

Laparoscopic rectal surgery has demonstrated its superiority over the open approach, however it still has some technical limitations that lead to the development of robotic platforms. Nevertheless the literature on this topic is rapidly expanding there is still no consensus about benefits of robotic rectal cancer surgery over the laparoscopic one. For this reason a review of all the literature examining robotic surgery for rectal cancer was performed. Two reviewers independently conducted a search of electronic databases (PubMed and EMBASE) using the key words “rectum”, “rectal”, “cancer”, “laparoscopy”, “robot”. After the initial screen of 266 articles, 43 papers were selected for review. A total of 3013 patients were included in the review. The most commonly performed intervention was low anterior resection (1450 patients, 48.1%), followed by anterior resections (997 patients, 33%), ultra-low anterior resections (393 patients, 13%) and abdominoperineal resections (173 patients, 5.7%). Robotic rectal surgery seems to offer potential advantages especially in low anterior resections with lower conversions rates and better preservation of the autonomic function. Quality of mesorectum and status of and circumferential resection margins are similar to those obtained with conventional laparoscopy even if robotic rectal surgery is undoubtedly associated with longer operative times. This review demonstrated that robotic rectal surgery is both safe and feasible but there is no evidence of its superiority over laparoscopy in terms of postoperative, clinical outcomes and incidence of complications. In conclusion robotic rectal surgery seems to overcome some of technical limitations of conventional laparoscopic surgery especially for tumors requiring low and ultra-low anterior resections but this technical improvement seems not to provide, until now, any significant clinical advantages to the patients

Robotic vs laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer: A retrospective comparative mono-institutional study

BACKGROUND: Robotic surgery has been developed with the aim of improving surgical quality and overcoming the limitations of conventional laparoscopy in the performance of complex mini-invasive procedures. The present study was designed to compare robotic and laparoscopic distal gastrectomy in the treatment of gastric cancer. METHODS: Between June 2008 and September 2015, 41 laparoscopic and 30 robotic distal gastrectomies were performed by a single surgeon at the same institution. Clinicopathological characteristics of the patients, surgical performance, postoperative morbidity/mortality and pathologic data were prospectively collected and compared between the laparoscopic and robotic groups by the Chi-square test and the Mann-Whitney test, as indicated. RESULTS: There were no significant differences in patient characteristics between the two groups. Mean tumor size was larger in the laparoscopic than in the robotic patients (5.3 ± 0.5 cm and 3.0 ± 0.4 cm, respectively; P = 0.02). However, tumor stage distribution was similar between the two groups. The mean number of dissected lymph nodes was higher in the robotic than in the laparoscopic patients (39.1 ± 3.7 and 30.5 ± 2.0, respectively; P = 0.02). The mean operative time was 262.6 ± 8.6 min in the laparoscopic group and 312.6 ± 15.7 min in the robotic group (P < 0.001). The incidences of surgery-related and surgery-unrelated complications were similar in the laparoscopic and in the robotic patients. There were no significant differences in short-term clinical outcomes between the two groups. CONCLUSIONS: Within the limitation of a small-sized, non-randomized analysis, our study confirms that robotic distal gastrectomy is a feasible and safe surgical procedure. When compared with conventional laparoscopy, robotic surgery shows evident benefits in the performance of lymphadenectomy with a higher number of retrieved and examined lymph nodes

Sirolimus (SRL) vs calcineurin inhibitors (CNI) in kidney transplantation from expanded-criteria donors: long-term results.

Introduction The use of organs from marginal donors (ECD) has become increasingly frequent because the growing organ shortage. The aim of the study was to evaluate the long-term outcome of ECD kidney recipients (KTR) treated with SRL de novo as an alternative to CNI. Patients and Methods Monocentric longitudinal retrospective study of 75 KTR from ECD, from 2000 to 2005, with a follow-up of 127 ± 52 months. SRL group = 25 pts treated with SRL + MMF + steroid, CNI group = 50 pts treated with CNI + MMF + steroid. The two KTR groups were similar for age (58 ± 7 vs 57 ± 7 years) and sex. Results No significant differences were found at 10 years for the overall survival of the patient (84% in the two groups) and of the graft (80% vs 92%, SRL vs CNI group). The renal function over time, the incidence of DGF and acute rejection were also comparable. There were no differences in the prevalence of infections, neoplasia, cardiovascular events and NODAT in the SRL group compared to CNI group. 6 patients dropped out in the SRL group for SRL related adverse effects. Conclusions The study confirms the excellent results of transplantation from ECD. The use of SRL can be considered a valid alternative to CNI for KTR from ECD, with good renal transplantation outcome and overall survival

Nutritional Aspects in Diabetic CKD Patients on Tertiary Care.

Abstract: Background and objectives: Diabetes is largely prevalent in the chronic kidney disease (CKD) population. Both conditions have metabolic and nutritional abnormalities that aect body composition and the presence of diabetes makes the dietary management of CKD patients more dicult. The aim of this study was to assess peculiar nutritional and functional aspects of diabetic patients in an adult/elderly CKD population, and their predictive significance. Materials and methods: This prospective cohort study included 144 out-patients aged &gt;55 years, aected by stage 3b-4 CKD, on tertiary care clinic; 48 (40 males) were type 2 diabetics and 96 (80 males) were nondiabetics. The two groups have similar age, gender, and residual renal function (30 9 vs. 31 11 mL/min1.73). All patients underwent a comprehensive nutritional and functional assessment and were followed for 31 14 months. Results: Diabetic CKD patients showed higher waist circumference and fat body mass, lower muscle mass, and lower number of steps per day and average daily METs. Meanwhile, resting energy expenditure (REE), as assessed by indirect calorimetry, and dietary energy intake were similar as well as hand-grip and 6 min walking test. Diabetic patients did not show a greater risk for all-cause mortality and renal death with respect to nondiabetics. Middle arm muscle circumference, phase angle, serum cholesterol, and serum albumin were negatively related to the risk of mortality and renal death after adjustment for eGFR. Conclusions: CKD diabetic patients diered from nondiabetics for a greater fat mass, lower muscle mass, and lower physical activity levels. This occurred at the same REE and dietary energy intake. The outcome of diabetic or nondiabetic CKD patients on tertiary care management was similar in terms of risk for mortality or renal death. Given the same residual renal function, low levels of muscle mass, phase angle, serum albumin, and cholesterol were predictive of poor outcome. Overall, a malnutrition phenotype represents a major predictor of poor outcome in diabetic and nondiabetic CKD patients

Image_1_Mutations matter: An observational study of the prognostic and predictive value of KRAS mutations in metastatic colorectal cancer.jpeg

BackgroundAbout half of metastatic colorectal cancers (CRCs) harbor Rat Sarcoma (RAS) activating mutations as oncogenic driver, but the prognostic role of RAS mutations is not fully elucidated. Interestingly, specific hotspot mutations have been identified as potential candidates for novel targeted therapies in several malignancies as per G12C. This study aims at evaluating the association between KRAS hotspot mutations and patient characteristics, prognosis and response to antiangiogenic drugs.MethodsData from RAS-mutated CRC patients referred to Careggi University Hospital, between January 2017 and April 2022 were retrospectively and prospectively collected. Tumor samples were assessed for RAS mutation status using MALDI-TOF Mass Spectrometry, Myriapod NGS-56G Onco Panel, or Myriapod NGS Cancer Panel DNA.ResultsAmong 1047 patients with available RAS mutational status, 183 KRAS-mutated patients with advanced CRC had adequate data for clinicopathological and survival analysis. KRAS mutations occurred at codon 12 in 67.2% of cases, codon 13 in 23.5%, codon 61 in 2.2%, and other codons in 8.2%. G12C mutation was identified in 7.1% of patients and exon 4 mutations in 7.1%. KRAS G12D mutation, as compared to other mutations, was significantly associated with liver metastases (1-sided p=0.005) and male sex (1-sided p=0.039), KRAS G12C mutation with peritoneal metastases (1-sided p=0.035), KRAS G12V mutation with female sex (1-sided p=0.025) and no surgery for primary tumor (1-sided p=0.005). No associations were observed between specific KRAS variants and age, ECOG PS, site of primary tumor, pattern of recurrence for resected patients, and lung, distant lymph node, bone, or brain metastases.Overall survival (OS) was significantly longer in patients with KRAS exon 4 mutations than in those with other KRAS mutations (mOS 43.6 months vs 20.6 months; HR 0.45 [0.21-0.99], p=0.04). No difference in survival was observed for mutations at codon 12/13/61 (p=0.1). Treatment with bevacizumab (BV) increased significatively mPFS (p=0.036) and mOS (p=0.019) of the entire population with a substantial benefit in mOS for G12V mutation (p=0.031).ConclusionsPatterns of presentation and prognosis among patients with specific RAS hotspot mutations deserve to be extensively studied in large datasets, with a specific attention to the uncommon isoforms and the role of anti-angiogenic drugs.</p