Assessing Nephrological Competence among Geriatricians: A Proof of Concept Internet Survey

Chronic kidney disease (CKD) is highly prevalent in the elderly and negatively impacts survival and health status. Thus, nephrological competence is mandatory for a skilled geriatrician. The present study aimed to assess nephrological competence in a sample of geriatricians recruited through a web survey. To this aim, a 12-items questionnaire was produced by an expert panel of nephrologists and geriatricians and was available online for members of the Italian Society of Gerontology and Geriatrics (SIGG). Two-hundred-eighty-seven geriatricians volunteered to fill in the questionnaire. The majority of them indirectly estimated the glomerular filtration rate (GFR) using mainly the Cockroft-Gault (C-G) formula. Selected nephrological exams, such as urinary Na and serum D-vitamin measurements, did not qualify as routine exams although the majority of geriatricians supplemented their patients with fat-soluble secosteroids. Ten percent of geriatricians asked for nephrological consultation only for stage 5 CKD patients and 30,9% only for stage 4 or 5. Erythropoietin supplementation was common practice for the majority of geriatricians, while only one third of them systematically used a procedure intended to prevent the contrast induced nephropathy (CIN). Finally, an alleged 50% adherence to the international guidelines for the management of CKD patients emerged from the questionnaire. Overall, results from this survey strongly recommend promoting nephrological education among geriatricians. Didactic standards for in training geriatricians need to be updated and the cooperation between geriatrics and nephrological societies promoted

"Dietaly": Practical issues for the nutritional management of CKD patients in Italy

Evidence exists that nutritional therapy induces favorable metabolic changes, prevents signs and symptoms of renal insufficiency, and is able to delay the need of dialysis. Currently, the main concern of the renal diets has turned from the efficacy to the feasibility in the daily clinical practice. Herewith we describe some different dietary approaches, developed in Italy in the last decades and applied in the actual clinical practice for the nutritional management of CKD patients. A step-wise approach or simplified dietary regimens are usually prescribed while taking into account not only the residual renal function and progression rate but also socio-economic, psychological and functional aspects. The application of the principles of the Mediterranean diet that covers the recommended daily allowances for nutrients and protein (0.8 g/Kg/day) exert a favorable effect at least in the early stages of CKD. Low protein (0.6 g/kg/day) regimens that include vegan diet and very low-protein (0.3-0.4 g/Kg/day) diet supplemented with essential amino acids and ketoacids, represent more opportunities that should be tailored on the single patient’s needs. Rather than a structured dietary plan, a list of basic recommendations to improve compliance with a low-sodium diet in CKD may allow patients to reach the desired salt target in the daily eating. Another approach consists of low protein diets as part of an integrated menu, in which patients can choose the “diet” that best suits their preferences and clinical needs. Lastly, in order to allow efficacy and safety, the importance of monitoring and follow up of a proper nutritional treatment in CKD patients is emphasized

Management of targeted therapies in cancer patients with chronic kidney disease, or on haemodialysis: An Associazione Italiana di Oncologia Medica (AIOM)/Societa' Italiana di Nefrologia (SIN) multidisciplinary consensus position paper

Abstract The increasing availability of novel biological anticancer agents has greatly improved the outcome of several cancer patients; unfortunately, data regarding efficacy, safety and pharmacokinetics of many of these agents in patients with chronic renal disease or on hemodialysis are scanty. Furthermore these results are controversial and a treatment strategy has not yet been established. Therefore, the Associazione Italiana di Oncologia Medica and the Societa italiana di Nefrologia undertook the present work aiming at providing health professionals with a tool for easier clinical management of target therapies in this setting of patients. A web-based search of MEDLINE/PubMed library data published from 2000 to June 2018 has been performed. More than one hundred papers, including recommendations and expert opinions, were selected and discussed by the authors. A panel of experts provided additional biological and clinical information, helping in clarifying some issues in the absence of clear-cut information from the literature

Central Venous Stenosis after Hemodialysis: Case Reports and Relationships to Catheters and Cardiac Implantable Devices

The appropriate vascular access for hemodialysis in patients with cardiac implantable electronic devices (CIED) is undefined. We describe two cases of end-stage renal disease patients with CIED and tunneled central venous catheter (CVC) who developed venous cava stenosis: (1) a 70-year-old man with sinus node disease and pacemaker in 2013, CVC, and a Brescia-Cimino forearm fistula in 2015; (2) a 75-year-old woman with previous ventricular arrhythmia with implanted defibrillator in 2014 and CVC in 2016. In either case, after about 1 year from CVC insertion, patients developed superior vena cava (SVC) syndrome due to stenosis diagnosed by axial computerized tomography. In case 1, the patient was not treated by angioplasty of SVC and removed CVC with partial resolving of symptoms. In case 2, a percutaneous transluminal angioplasty with placement of a new CVC was required. To analyze these reports in the context of available literature, we systematically reviewed studies that have analyzed the presence of central venous stenosis associated with the simultaneous presence of CIED and CVC. Five studies were found; two indicated an increased incidence of central venous stenosis, while three did not find any association. While more studies are definitely needed, we suggest that these patients may benefit from epicardial cardiac devices and the insertion of devices directly into the ventriculus. If the new devices are unavailable or contraindicated, peritoneal dialysis or intensive conservative treatment in older patients may be proposed as alternative options

GERIATRIC NEPHROLOGY: AN OVERVIEW

Introduction: Chronic kidney disease (CKD) is a highly prevalent condition and its prevalence is increasing worldwide, particularly in adults aged ≥ 70 years. Epidemiological studies showed that as many as 20–54% of the older adults suffer from CKD in stages 3-5. Nevertheless the question whether this lower eGFR is a consequence of kidney disease or if it is the result of a physiological aging is still debated, even if it implies a reduced renal reserve and vulnerability to drugs overdose with increased risk of acute kidney injury (AKI). Materials and methods: PubMed search was conducted for available English literature, describing the actual knowledge about specific and frequent issues reported in the acute and chronic kidney disease in older adults. Prospective and retrospective studies, as well as meta-analyses and latest systematic reviews were included. Results:Most of the studies examined and reviewed were discarded for wrong population or intervention or deemed unfit. Only 103 met the inclusion criteria for the review. The studies included in the review were grouped into two areas: chronic and acute kidney disease in older adults and we have analysed the peculiar and frequently found issues in this population. Conclusions: The geriatric population is increasing worldwide.We should consider peculiar aspects of this population, such as sarcopenia, malnutrition, psychological and cognitive deficits and increased risk of AKI, in order to reach a good quality of life, with improved doctor / patient relationship, a greater adherence to therapy, a reduction in health care costs, and if possible, adequate "end of life", as far as it is approved by the patient and his family. The achievement of these objectives requires an organized work in multidisciplinary teams that evaluate overall the geriatric patient

Classic and follicular variant of papillary thyroid microcarcinoma: 2 different phenotypes beyond tumor size

Context: Despite the wide revision of current guidelines, the management of papillary thyroid microcarcinoma (mPTC) still has to be decided case by case. There is conflicting evidence about the role of more frequent histological subtypes, and no data about potential differences at presentation. Objective: Our aim was to compare the phenotype of the 2 most frequent mPTC variants, namely, classical papillary thyroid microcarcinoma (mPTCc) and the follicular variant of papillary thyroid microcarcinoma (mFVPTC). Methods: Retrospective observational study, from January 2008 to December 2017 of a consecutive series of patients with mPTCc and mFVPTC. All cases were classified according to the 2015 American Thyroid Association (ATA) risk classification. Clinical and preclinical features of mPTCc and mFVPTC at diagnosis were collected. The comparison was also performed according to the incidental/nonincidental diagnosis and differences were verified by binary logistic analysis. Results: In total, 235 patients were eligible for the analysis (125 and 110 mPTCc and mFVPTC, respectively). Compared with mPTCc, mFVPTCs were more often incidental and significantly smaller (4 vs 7mm) (P <. 001 all), possibly influenced by the higher rate of incidental detection. mFVPTC and incidental (P <. 001 both) tumors were significantly more often allocated within the low-risk class. A logistic regression model, with ATA risk class as the dependent variable, showed that both mFVPTC (OR 0.465 [0.235-0.922]; P =. 028]) and incidental diagnosis (OR 0.074 [0.036-0.163]; P <. 001) independently predicted ATA risk stratification. Conclusion: mFVPTC shows some differences in diagnostic presentation compared with mPTCc, and seems to retain a significant number of favorable features, including a prevalent onset as incidental diagnosis

Low-protein diets for chronic kidney disease patients: The Italian experience

open20Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients.openBellizzi, Vincenzo; Cupisti, Adamasco; Locatelli, Francesco; Bolasco, Piergiorgio; Brunori, Giuliano; Cancarini, Giovanni; Caria, Stefania; De Nicola, Luca; Di Iorio, Biagio R; Di Micco, Lucia; Fiaccadori, Enrico; Garibotto, Giacomo; Mandreoli, Marcora; Minutolo, Roberto; Oldrizzi, Lamberto; Piccoli, Giorgina B; Quintaliani, Giuseppe; Santoro, Domenico; Torraca, Serena; Viola, Battista FBellizzi, Vincenzo; Cupisti, Adamasco; Locatelli, Francesco; Bolasco, Piergiorgio; Brunori, Giuliano; Cancarini, Giovanni; Caria, Stefania; De Nicola, Luca; Di Iorio, Biagio R; Di Micco, Lucia; Fiaccadori, Enrico; Garibotto, Giacomo; Mandreoli, Marcora; Minutolo, Roberto; Oldrizzi, Lamberto; Piccoli, Giorgina B; Quintaliani, Giuseppe; Santoro, Domenico; Torraca, Serena; Viola, Battista F

“Searching for the peak: Google Trends and the COVID-19 outbreak in Italy”

One of the di culties faced by policy makers during the COVID-19 outbreak in Italy was the monitoring of the virus di usion. Due to changes in the criteria and insu cient resources to test all suspected cases, the number of `con rmed infected' rapidly proved to be unreliably reported by o cial statistics. We explore the possibility of using information obtained from Google Trends to predict the evolution of the epidemic. Following the most recent developments on the statistical analysis of longitudinal data, we estimate a dynamic heterogeneous panel. This approach allows to takes into account the presence of common shocks and unobserved components in the error term both likely to occur in this context. We nd that Google queries contain useful information to predict number patients admitted to the intensive care units, number of deaths and excess mortality in Italian regions