Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia最新文献

Nocardiosis is an uncommon but serious opportunistic bacterial infection caused by the genus Nocardia. Immunosuppression significantly increases the risk of infection, with an incidence of 0.4% to 3.6% in renal transplant patients. This disease primarily affects the lungs, skin, and central nervous system (CNS), but it can also disseminate to other parts of the body, significantly increasing the associated mortality. Although it can be challenging, early diagnosis is crucial, as it may be life-saving. The primary treatment for nocardiosis involves long-term antibiotic therapy. However, this treatment is often complicated by poor tolerance due to renal function impairment, requiring close monitoring and individualized treatment. In this report, we present two cases of nocardiosis, highlighting the complexities of diagnosis and management in renal transplant patients.

Peritoneal dialysis (PD) is used in Italy for less than 10% of patients on dialysis, with considerable inter-regional variability. The ALTEMS research using HTA methodology set out to assess whether this is justified on economic grounds. Effectiveness measured in terms of Quality Adjusted Life Years (QALY) is 1.20 for PD compared to the 0.94 of hospital hemodialysis (HD). In terms of cost-utility analysis, PD is therefore "dominant" as it is more effective and less costly, and as a result is the treatment of choice from both clinical and economic points of view, as well as from both social and SSN perspectives. On Budget Impact Analysis (BIA), the real annual cost per patient from the social perspective is € 24,142 for PD and € 42,231 for HD. A hypothetical greater use of PD, with an annual increase of at least 5% of patients on PD, would result in savings over a 5-year period of close to 100 million euro.

Gene therapy is an innovative medical approach that involves altering or replacing defective genetic material to treat or potentially cure genetic disorders. This technique primarily uses viral or non-viral vectors to deliver genetic material into cells, aiming to restore normal gene function. The therapy has the potential to address a wide range of diseases, including genetic, cardiovascular, and neurodegenerative disorders. In this review, the focus will be on gene therapies related to kidney diseases. Topics to be covered include the use of messenger ribonucleic acid (mRNA) therapies for conditions such as hypertension and kidney cancer, as well as targeted gene therapies using small interfering RNA (siRNA) and adeno-associated viruses to treat glomerular diseases and prevent kidney damage. The application of gene therapies in treating well-known genetic conditions, such as Alport syndrome and cystinosis, will also be discussed. Additionally, the review will explore the progress of RNA interference (RNAi) therapies in acute kidney injury (AKI) and chronic kidney disease (CKD). Finally, the challenges and risks associated with gene therapy, including immune responses, insertional mutagenesis, and the high costs of treatment, will be examined.

Onconephrology represents a burgeoning subspecialty within nephrology, dedicated to ensuring optimal oncological management for cancer patients with pre-existing or cancer-therapy-induced renal impairment. Epidemiological data regarding the early impact of renal function alterations in Italian oncology patients are currently lacking. This study presents a three-year single-center experience from an onconephrology clinic, evaluating patients with solid tumors and renal abnormalities, specifically acute kidney injury (AKI) or proteinuria. A total of 254 patients with solid malignancies were included. Among these, 153 (60.2%) were referred due to AKI, predominantly AKIN stages I-II, with 71 cases (46.4%) attributed to oncological treatment. Notably, antineoplastic therapy was permanently discontinued in only 27 patients (13.1%). The most frequent tumor types were pulmonary (17.5%) and gynecological (17.9%) cancers. Checkpoint inhibitors were the therapies most commonly associated with AKI. During the follow-up period, 83 of the 254 patients (34.5%) died, with 46 (55%) of these having experienced concurrent AKI, suggesting a potential risk for chronic kidney disease development. Among the surviving patients, 71% exhibited a decline in estimated glomerular filtration rate of <30 ml/min. This experience underscores the intricate relationship between cancer therapies and renal function, highlighting the critical need for early and continuous onconephrological assessment in this patient population.

Background. The measured electrolyte composition of the dialysate (D) should be in close approximation to that of the hemodialysis prescription. However, to the best of our knowledge, no studies have compared prescribed and measured hemodialysate electrolyte levels other than sodium (Na+) and calcium (Ca++). Objective. To determine the difference between the measured and prescribed electrolyte concentrations in the hemodialysate and the factors responsible for it. Methods. In this retrospective study, data from biochemical analyses of the hemodialysate, acid concentrate and product water were collected. Data on a fraction of samples with measured electrolyte concentrations within the permitted range of the prescribed value were collected, and the reasons for the discrepancy between the prescribed and measured values were analysed. Results. In our study, 91.87%, 59.22%, 54.41% and 6.84% of the samples had DNa+, DK+, DCa++ and DMg++ values, respectively, within the range of the prescribed concentrations. The Ca++ content in the acid concentrate (Part A) and changes in the prescribed DNa+ or DB (part of the dialysate contributed by Part B, which contained sodium chloride and sodium bicarbonate in our study) were responsible for the discrepancy between the prescribed and measured DCa++ values. For an 8 mmol/L (5.7%) reduction in the prescribed DNa+, the measured DCa++ was reduced by 9.07% ± 1.68%. A reduction in the prescribed DB by 8 mmol/L led to an increase in the measured DCa++ of 10.31% ± 2.02%. High measured DMg++ and DCa++ values were observed in certain dialysate samples owing to higher-than-expected magnesium and calcium contents in the acid concentrate. With an 8 mmol/L (5.7%) reduction in the prescribed DNa+, the measured DK+ decreased by 10.56% ± 3.56%. DNa+ was correlated with the dialysate conductivity (R = 0.919) and increased with decreasing prescribed DB. Conclusion. The calcium in the acid concentrate and the prescribed DNa+/DB were responsible for the discrepancy between the prescribed and measured DCa++. The prescribed DNa+ change was responsible for the discrepancy between the measured and prescribed DK+. Furthermore, a strong correlation was observed between the dialysate conductivity and DNa+ in our study, where the dialysate conductivity increased with decreasing DB, while DNa+ remained constant.

Endovascular systems represent an interesting technique for the non-surgical creation of an arteriovenous fistula (AVF) for hemodialysis. The aim was to evaluate the efficacy and the safety of the application of an endovascular system to perform AVF in ESKD patients treated at our center. Methods. Color Doppler ultrasound was used to assess anatomical criteria for patient's eligibility. Accurate clinical and instrumental post-procedural follow-up was carried out. Results. Endovascular AVF (endoAVF) was successfully created in 7 patients without peri-operative complications. During the procedure, coiling in the brachial vein (n = 4) and angioplasty were performed (n = 1) to divert more flow through the perforator to the superficial veins (cephalic, median cubital and/or basilic veins). Color Doppler ultrasound showed optimal 24-hour, 7-day, 30-day, 6-month and 12-month AVF flow rates. All endoAVF met maturation criteria within the first month and were successful cannulated. Primary patency rates at 4, 6 and 18 months were 100%, 85.7%, and 71.4%, respectively. Cumulative patency rate during follow-up (median 16 months) was 100%. During follow-up, 2 patients (29%) required corrective interventions with a re-intervention rate of 0.21 procedures per patient year. Conclusions. The study confirms this alternative technique for AVF creation as safe and effective. The implementation of a well-trained team including nephrologists and interventional radiologists is crucial to obtain and maintain a well-functioning endoAVF.

The Census carried out by the Italian Society of Nephrology's Peritoneal Dialysis (PD) Project Group has been following the evolution of PD for 20 years. For the first time, the latest edition in 2024 was followed up by an on-line audit conducted between 28/04/2025 and 09/05/2025. With 185 of the 228 Centers which used PD in 2024 taking part, the Audit investigated a number of questions which are controversial or relatively unexplored: 1) the incremental dialysis prescription in CAPD; 2) empiric peritonitis therapy; 3) the prophylaxis of exit site infections (ESI); 4) types of peritoneal catheter used; 5) the use of telemedicine. There is no consensus on the incremental prescription in CAPD. Most start with a single exchange, and in the event of two exchanges the majority keep the abdomen empty for part of the day. However, 37.4% of the 162 Centers using incremental PD begin from 2+ exchanges, while 26.5% in two-exchange CAPD keep the abdomen always full. A fair degree of variation was also observed regarding the type of catheter used, although 75.7% of the Centers use only one type in their Center. Almost all the Centers follow ISPD recommendations on empiric peritonitis therapy and ESI/TI prophylaxis, the validity of which is confirmed by the constant reduction in the drop-out rate for peritonitis recorded over the last 20 years. Finally, Telemedicine data show the ever-increasing use of this tool, notably Telemonitoring, whereas only a minority of the Centers use Teleassistance - in particular Televisits - which is particularly useful in Assisted PD.

The PIRP Project (Progressive Renal Insufficiency Prevention), launched in Emilia-Romagna in the early 2000s, was created to establish a network between general practitioners and nephrologists aimed at the early identification of chronic kidney disease (CKD), slowing its progression, and improving clinical outcomes. The project included several phases: a training phase for general practitioners, the establishment of dedicated outpatient clinics, and the creation of a regional electronic registry, which today includes more than 38,000 patients. The results have shown a reduction in CKD progression, fewer urgent dialysis starts, and better control of comorbidities. PIRP differs from the national PDTA for CKD in its operational and regional approach, based on real-world data and multidisciplinary co-management, whereas the PDTA represents a general regulatory framework. The project has developed predictive models (such as CT-PIRP), inspired comparative European studies, and today stands as a model of integrated healthcare, useful for the implementation of nephroprotective drugs and artificial intelligence. Twenty years after its inception, PIRP remains an example of proactive and collaborative medicine, anticipating modern paradigms of population health management.

The term "dyslipidemia", commonly used in a broad sense, refers to a clinical condition characterized by alterations in the lipid profile across all its components: total cholesterol (TOT-C), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG). An imbalance in one or more of these parameters contributes to increased cardiovascular risk, primarily driven by the acceleration of atherosclerotic processes. Currently, numerous therapeutic options are available for the management of dyslipidemia, ranging from more conventional treatments - such as 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors and selective cholesterol absorption inhibitors - to more recently introduced therapies, including proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), bile acid sequestrants, monoclonal antibodies, dietary supplements, cholesterol synthesis and absorption inhibitors, and LDL-C excretion promoters. The aim of this review is to provide a systematic overview of the various therapeutic approaches currently available, in light of two key factors: the broad spectrum of pharmacological options, and the recent regulatory updates regarding prescriptive authority, which now allows nephrologists to prescribe newly introduced lipid lowering agents.

According to World Health Organization data from July 2023, human immunodeficiency virus (HIV) remains a global public health issue, having claimed approximately 40 million lives so far, with ongoing transmissions in every country globally. Changes in hematologic parameters, such as anemia or thrombocytopenia, are among the most common complications in people living with HIV/AIDS (PLWHA). These complications arise due to the bone marrow being targeted by the combined effects of HIV infection, inflammatory mediators released in response to the infection, and opportunistic pathogens. HIV-associated thrombotic thrombocytopenic purpura (TTP) is a rare condition that can lead to end-organ ischemia and requires prompt treatment to prevent permanent organ damage. We present the case of a previously healthy 54-year-old man who presented at the emergency department with profound asthenia and unexplained weight loss of 10 kg over a few weeks. Diagnostic investigations were remarkable for a positive HIV rapid antigen/antibody combination test, severe thrombocytopenia and hemolytic anemia. As HIV-associated TTP was the likely diagnosis, the patient was transferred to the Division of Nephrology for therapeutic plasma exchange (TPE). Monitoring platelet counts and hemoglobin levels in HIV/AIDS patients affected by HIV-associated TTP is essential for assessing disease progression and identifying thrombocytopenia or its related clinical symptoms.