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

Introduction. Patients with chronic kidney disease undergoing renal replacement therapy have complex care needs. To address this, nephrology and dialysis nurses must possess expertise in advanced specialist and disciplinary skills. The aim of this review is to analyze post-graduate academic training pathways and clinical-care training in the field of nephrology and dialysis nursing in the Italian context. Methodology. A narrative review of the literature was conducted in May 2024, using databases such as CINAHL and Medline-PubMed, with a selection criterion limited to primary and secondary studies published in Italian and English. To supplement the search, particularly within the Italian context, grey literature sources were consulted. Results. Post-graduate nephrology nursing education in Italy is mainly offered through First-Level Masters, as well as Second Level Masters and specialization courses, which are provided at various academic institutions. Analysis of the educational programs revealed the presence of common "core" teachings across all pathways, covering renal disease pathophysiology, hemodialysis, peritoneal dialysis, and dialysis nursing care, alongside significant heterogeneity in other proposed teachings. Clinical-care training emerged as a fundamental aspect in both post-graduate education, professional integration for newcomers, and continuous professional development. Conclusions. The growing healthcare need for specialist skills suggests the necessity of integrating field-based training with standardized post-graduate academic pathways, possibly in collaboration with relevant Nursing Scientific Societies. This synergy would not only promote the enhancement of nursing competencies but also ensure a high quality of care delivery.

Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) primarily affects small- and medium-sized arteries, including kidney vessels, thus causing rapidly progressive glomerulonephritis. The pathogenesis of AAV is intricate and several factors, including infections, are known to possibly trigger the autoimmune process. Numerous studies have reported that SARS-CoV-2 might cause acute kidney injury (AKI). To date, a modest number of AAV with COVID-19 cases has been reported. Herein, we discuss the case of a 61-year-old man with new-onset of diffuse proliferative ANCA-associated glomerulonephritis after COVID-19.

Central venous catheter-related thrombosis is a frequent non-infectious complication, typically associated with catheter dysfunction and hemodialysis inadequacy. Central venous catheters (CVCs) are categorized into non-tunnelled and tunnelled types, wherein the choice depends on patient's clinical conditions and the diagnostic and therapeutic workup. Tunnelled CVCs (tCVCs) are sought whenever an arteriovenous fistula is unfeasible or as primary access in patients with poor prognosis. Dysfunction is defined as the inability to maintain adequate blood flow within the prescribed dialytic session. Amongst non-infectious complications causing tCVC malfunctioning, thrombosis is the most frequent, and it is further classified into intrinsic (being endoluminal, pericatheter or fibrin sleeve-associated thrombosis) and extrinsic forms (including mural and atrial thrombosis). Diagnosis requires imaging tests like chest X-ray or abdominal X-ray, echocardiography, dynamic catheterography and computed tomography. Pharmacological treatment involves use of local thrombolytic agents. In case of extrinsic thrombosis, systemic anticoagulation is mandatory, occasionally requiring tCVC replacement. Prevention of thrombotic complications includes adequate positioning and appropriate use of the tCVC, with anticoagulant/antimicrobial-based locking solutions playing a crucial role in this context. In cases of extrinsic thrombosis, treatment options vary based on thrombus size, ranging from a conservative approach availing of systemic anticoagulation to surgical interventions like thrombectomy or thrombus aspiration, possibly associated with tCVC removal. In conclusion, late dysfunction of tCVCs is primarily due to thrombosis, thus requiring diagnostic imaging and specific drug therapies. Prevention is crucial to minimize complications.

Introduction. Rituximab (RTX) holds promise as a treatment for idiopathic membranous nephropathy (IMN). While effective in standard regimens, the application of RTX is hampered by cost burdens and severe side effects. To address these issues, low-dose RTX has been proposed as an intervention strategy. Yet, the efficacy of this approach in treating IMN remain subject of debate. This systematic review and meta-analysis seek to examine the effectiveness of low-dose RTX in adult patients with IMN. Methodology. A literature search was conducted using PubMed, Wiley Online Library, ScienceDirect, Cochrane Library, Springer and other sources, published between 2004 and 2024. Specifically, articles reporting the intravenous application of RTX at doses lower than four weekly infusions of 375 mg/m² or two infusions of 1 gram each on day 0 and day 15 were considered for inclusion. The primary outcomes were complete response (CR) and partial response (PR) rates at last follow-up. Secondary endpoints included serum creatinine levels, serum albumin levels, 24-hour proteinuria levels, protein-creatinine ratio (PCR), estimated glomerular filtration rate (eGFR) and anti-PLA2R antibody levels. Results. Sixteen articles were included in this meta-analysis. The pooled analysis of odds ratios (OR) revealed that both main-line (OR = 0.48, 95% CI = 0.30-0.75, p = 0.001) and second-line (OR = 0.27, 95% CI = 0.11-0.67, p = 0.005) RTX treatments induced complete remission (CR) in IMN patients. At the last follow-up, patients treated with both main-line (mean difference [MD] = 1.45, 95% CI = 1.00-1.91, p < 0.00001) and second-line (MD = 0.88, 95% CI = 0.23-1.53, p < 0.00001) RTX treatments showed a significant increase in serum albumin levels. Conversely, in the analysed second line RTX therapy patients, low eGFR trend was noted in the post treatment arm compared to baseline levels (MD = 10.57, 95% CI = 0.30-20.83, p = 0.04). Moreover, RTX was found to be effective in reducing PCR (MD = 24.10, 95% CI= 1.07 to 47.13, p = 0.04) and depleting PLA2R antibody levels (MD = 127.36, 95% CI = 14.90-239.81, P = 0.03). However, RTX might be less effective in lowering proteinuria and serum creatinine levels in patients with nephrotic syndrome. Conclusion. Rituximab in a low-dose regimen is quite effective in treating adult patients with IMN. Therefore, it can be considered a promising treatment for both main-line and rescue therapy. More randomized controlled trials and research on optimizing the low-dose regimen, based on various health factors, are warranted.

Generalized edema is commonly encountered in everyday clinical practice, usually due to heart, liver and renal disease. On the other hand, edema related to fluid extravasation associated with hypotension, hemoconcentration and hypalbuminemia is a rare clinical disorder. We present a case of a 61-year-old man with 3 subsequent endothelium permeability alteration episodes with increasing severity related to Sars-Cov-2 infection. During the last episode he was admitted to the intensive care unit, a monoclonal gammopathy was diagnosed and acute kidney injury requiring continuous renal replacement therapy developed. Systemic capillary leak syndrome or Cklarkson's disease was diagnosed, and the three phases of the condition were recognized, i.e. the prodromal phase, the acute shock phase and the recovery phase. The patients recovered and his kidney function returned to normal values. Nephrologists should be aware of plasma leakage syndromes being their management, especially fluid infusion, difficult due to the risk of complications such as acute kidney injury, compartment syndrome and neuropathy, rhabdomyolysis, myocardial edema, pericardial-pleural-abdominal effusion, deep vein thrombosis and acute pulmonary edema. Sars-Cov-2 infection appears to have increased the frequency of this rare disease.

Chronic Kidney Disease associated Pruritus (CKD-aP) in hemodialysis affects approximately 38% of our patients. It is not associated with any dermatological lesion other than the common scratching lesions, a consequence of the symptom itself. The causes associated with itching have been studied in various treatments. However, there is a relatively rare condition that involves 10% of hemodialysis patients, known as reactive perforating collagenosis. This is a pathological condition secondary to chronic hemodialysis therapy, where widespread itching develops, associated with a peculiar reactive dermatosis with perforation of the dermis and development of dermal-epidermal continuity solutions with extrusion of matrix components dermal. In this work we report our experience with a diagnosed case of this condition.

Dengue is an arboviral infection transmitted by the mosquito of the Aedes genus, widespread especially in tropical and subtropical regions but now with worldwide involvement. Cases of contagion are also progressively increasing in Europe, and the differential diagnosis with other infections is not always easy. Renal involvement with acute renal failure is possible and caused by the direct action of the virus, hemodynamic instability, rhabdomyolysis, or acute glomerular damage. In patients most at risk of renal involvement, there is high morbidity and mortality, with more extended hospital stays and follow-ups over time, which increases the burden on healthcare systems. Knowledge of this infection by nephrologists is essential for reducing morbidity, mortality, and, therefore, healthcare costs.

Objective. Patients with nephrotic syndrome (NS) have an increased risk of developing acute ischemic stroke (aIS) and intracranial hemorrhage (ICH). However, the informations on the risk factors for these outcomes are unknown. The aim of this study was therefore to determine the risk factors for stroke among patients with NS. Methods. A multicentric retrospective cohort of patients who developed aIS or ICH, following a diagnosis of NS between 2010 and 2021 was assembled. NS patients who did not develop stroke at follow-up were assembled as non-matched controls from the same study period. Cox regression yielding a hazard ratio (HR) with a 95% confidence interval was applied to investigate the potential risk factors for stroke among patients with NS. A meta-analysis on the current litterature was also performed. Results. With a mean follow-up of 6 years, a total of 45 patients with NS were included of which 14 were diagnosed with aIS and 4 with ICH at follow-up. Significant risk factors for stroke in patients with NS were diabetes mellitus (DM) (HR 2.85, 95%CI 1.10-7.49; p-value = 0.03), diabetic nephropathy (HR 2.74, 95% CI 1.06-7.07; p-value = 0.038) smoking (HR 8.29, 95% CI 2.20-31.2; p-value = 0.002), prior arterial thromboembolic events (ATEs) (HR 2.86, 95% CI 1.09-7.53: p-value = 0.03) and age > 55 years old (HR 4.84, 95% CI 1.48-15.8; p-value = 0.009). Administration of low molecular weight heparin (LMWH) (HR 0.88, 95% CI 0.22-3.43; p-value = 0.848) did not affect the risk-estimates for developing stroke in patients with NS. Meta-analysis including 1091 patients revealed prior ATEs, diabetes, hypertension and smoking to be risk factors for ATEs among patients with NS. Conclusion. In this study we found older age, DM, prior ATEs and smoking to increase the risk of developing stroke in patients with NS, while notably LMWH had no protective effects. Our findings may serve as an aid for physicians in managing and identifying high-risk patients for stroke in this subpopulation.

The psychological clinical activity (2019-present) addressed to patients and family members carried out in the Nephrology and Dialysis Unit of Chieti Hospital allowed to achieve various objectives: the support of the patient and her/his family in the process of adaptation to the disease and its therapy, and the support of the treatment team to guarantee and safeguard the relationship with patient. Here we report the training interventions to healthcare personnel, which aim to analyze the communication methods and defensive styles used in the relationship with the patient, to explore the emotional perceptions of the self that can influence the therapeutic relationship. Our results show that the psychological intervention to the healthcare personnel working in a nephrology/dialysis unit may represent an effective tool for preventing burnout and a resource for increasing motivation in performing the professional activity.