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

The purpose of this document is to highlight the current issues limiting the expansion of the transplant program and to outline the actions, resources, and organizational measures needed to optimize and promote kidney transplantation in Italy, especially transplant from living donors. A primary goal of the document is to promote both qualitative and quantitative uniformity of transplant activity across the national territory, thereby reducing the existing geographical disparities. To make enrollment in the transplant program faster and easier, the document sets out minimum group of diagnostic tests for both donor and recipient, specifying only certain cases where further tests are needed, since these often cause unacceptable delays in completing eligibility for the waiting list. The document will be presented to national health institutions (National Transplant Center - Istituto Superiore di Sanità) and may serve as a reference tool at the regional level for technical working groups on kidney transplantation within the Italian regions.

Arteriovenous fistula (AVF) for hemodialysis can lead to various complications in transplanted patients, particularly on an iatrogenic basis and due to hemodynamic changes: aneurysm - whether venous, arterial, or arteriovenous - is one such complication. Shear stress and the activation of oxygen radicals can affect the remodeling of the vessel wall (type IV and V collagen). We describe a case of a rare aneurysm of the anastomotic chamber. In January 2025, a 55-year-old woman with a well-functioning kidney transplant on triple anti-rejection therapy presented to our clinic. She complained of a painful pulsation at the site of the distal left radio-cephalic AVF anastomosis, which had developed over the past two days. An ultrasound-color Doppler examination revealed an aneurysm of the anastomotic chamber involving the radial artery. We recommended evaluation in the emergency department for surgical assessment. The patient underwent aneurysmectomy with reconstruction of the wall continuity and ligation of the AVF a few hours later. Conclusions. Thanks to the color Doppler ultrasound examination, we diagnosed a rare arteriovenous aneurysm of the AVF in a transplanted patient. Monitoring seems necessary in this category of patients for the management of severe complications that may be favored by anti-rejection therapy.

The demographic and epidemiological transition that Italy has undergone over the past 50 years has made palliative care (PC) essential in situations where active treatment is no longer proportionate. One of the major current and future challenges of palliative care lies in the management of non-oncological chronic diseases, particularly advanced organ failure and dementia. Individuals aged over 70 and 80 represent a significant proportion of the more than 45,000 chronic dialysis patients in Italy. These patients typically present with increased comorbidities, reduced life expectancy and quality of life, and a higher risk of hospitalization and in-hospital mortality. Moreover, older adults in these age groups also constitute the majority of the approximately 15% of patients with end-stage renal disease (ESRD) who continue exclusively with conservative management, never initiating renal replacement therapy. Over the past decade, interest in palliative care within the field of nephrology has grown substantially across the Western world. Decisions to withhold or withdraw dialysis vary widely by region, with higher rates observed in North America and Canada, and lower rates in Southern Europe. The Italian Society of Palliative Care (SICP) published with the Italian Society of Nephrology (SIN) and the Italian Society of Nephrology Nurses (SIAN), ten and six years ago respectively, a consensus document on the integration of palliative care in the management of chronic kidney disease. The objective of this study is to provide a comprehensive overview of the current state of palliative care practices within nephrology units across Italy.

Acute liver failure (ALF) and acute on chronic liver failure (ACLF) represent severely compromised clinical conditions, characterised by high mortality and often candidates for liver transplantation. Recently, non-biological extracorporeal treatments (ECLSD) have gained an increasing role as temporary support through the removal of water-soluble and albumin-bound toxins. This paper provides an overview of the main available devices, including SPAD (single pass Albumin Dialysis), MARS (Molecular Adsorbent Recirculation System), Prometheus (Fractionated Plasma Separation and Adsorption), Cytosorb, CPFA (Coupled Plasma Filtration Adsorption) and DPMAS (Dual Plasma Molecular Adsorption System), illustrating their technical characteristics, efficacy and limitations. Cytosorb, although originally designed for the treatment of systemic inflammatory conditions, has shown surprising efficacy in reducing bilirubin and bile acids, surpassing the results of MARS in some retrospective studies. Special attention is given to our centre's experience with the RAED (Recirculated Albumin Extended Dialysis) and RHENOB (Reemplazo Hepático No Biológico) techniques, based on recirculated albumin circuits, with or without regeneration by DPMAS. In a series of seven patients with ALF or ACLF treated with RHENOB, a significant reduction in bilirubin (25-50%) was observed after only a few sessions, without haemodynamic adverse events. One patient subsequently received a successful liver transplant, completing the biochemical stabilisation course. The RAED and RHENOB techniques appear to be innovative, effective, cost-effective approaches that can be applied even in centres without advanced technology. However, controlled prospective studies are needed to consolidate their use in clinical practice.

Hemodialysis performed with a low-temperature dialysate (< 36 °C) represents an effective strategy for preventing intradialytic hypotension and, more generally, for improving patient hemodynamics. Additional benefits from this approach may also extend to other systems, such as the cardiovascular and central nervous systems. Despite these undoubtedly favorable effects, some drawbacks have been reported, including significant patient discomfort, while data regarding extracorporeal clearance remain inconsistent. In light of these considerations, and through the analysis of major studies published in PubMed® over the past decade, we aim to provide a comprehensive and critical appraisal referred to as «cool dialysis».

Introduction. Physician-patient communication is a pivotal element in the management of chronic kidney disease (CKD), yet it is sometimes reduced to a mere transmission of information. Ineffective communication undermines therapeutic adherence, delays clinical decision-making, and negatively impacts patients' quality of life. Methods. We conducted a panoramic review of the literature, with a specific focus on nephrology context, examining how various aspects (communication barriers, patient expectations, use of multimedia tools, digital self-monitoring) affect clinical outcomes and can transform from critical issues into resources for improving the therapeutic alliance and adherence. Results. Evidence shows that: (1) physician-patient communication, expectations, and genuine understanding directly influence clinical outcomes; (2) digital tools such as educational/storytelling videos, online platforms, institutional social media channels, and dedicated apps improve health literacy and patient engagement; (3) self-monitoring and smart devices can help strengthen awareness and foster the doctor-patient relationship, even remotely; (4) therapeutic adherence can be significantly improved through empathetic and shared care relationships, including through digital media, countering misinformation and mistrust. Conclusions. Innovating communication in nephrology requires moving beyond the traditional information-delivery model, embracing narrative and digital approaches, and recognizing communication as a fully-fledged therapeutic intervention.

Introduction. Pain during arteriovenous fistula (AVF) cannulation remains a major concern among patients undergoing maintenance hemodialysis. This study was done to assess the effectiveness of cryotherapy in reducing patient perceived pain during AVF cannulation. Methods. This randomised crossover study was carried out on 111 hemodialysis patients. During the first four sessions, the patients received cryotherapy intervention and during next four sessions, the patients received standard care without cryotherapy. Pain was assessed using the Wong-baker faces pain rating scale. Results. There was a significant difference between pain scale with intervention and without intervention, with p value of 0.001. Conclusions. In hemodialysis patients, pain was reduced during AVF cannulation when cryotherapy was used.

Introduction. Chronic kidney disease (CKD) is a major complication in type 2 diabetes (T2D), leading to increased cardiovascular risk. Empagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT2i), has shown cardiorenal benefits in clinical trials, but real-world data in patients with moderate CKD are limited. Objectives. To retrospectively evaluate changes in estimated glomerular filtration rate (eGFR) following empagliflozin initiation in T2D patients with CKD (KDIGO 3A and 3B stages), focusing on the occurrence and impact of early eGFR decline ("dip") and associated metabolic outcomes and cardiovascular risk factors. Methods. This multicenter study included adult T2D patients with eGFR 30-60 mL/min/1.73 m² who started empagliflozin between October 2023 and April 2024. Clinical parameters were collected at baseline, 1 month, and 6 months. Subgroup analyses were conducted by CKD stage and eGFR dip status (>10% decline at 1 month). Results. Among 166 patients, 21.6% experienced an eGFR dip. Overall, eGFR increased by 2.75 mL/min/1.73m² at 6 months (p < 0.0001), with more pronounced improvement in non-dippers and CKD 3A patients. In dippers, eGFR partially recovered. HbA1c decreased by ~4 mmol/mol (despite use of concomitant glucose-lowering drugs decreased at empagliflozin initiation), weight by ~2 kg, and systolic blood pressure by ~4 mmHg. Empagliflozin discontinuation occurred in 4.2% of patients, mainly due to genitourinary infections. Discussion. Empagliflozin was associated with stabilization or improvement in renal function and modest metabolic benefits in T2D patients with CKD stage 3. The eGFR dip was infrequent and transient, supporting the continued use of empagliflozin in this population in real-world settings.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have redefined the therapeutic landscape of heart failure (HF), both with reduced (HFrEF) and preserved (HFpEF) ejection fraction. Historically, treatment has relied on diuretics to relieve congestion, with limited prognostic impact and dose-related adverse effects. SGLT2i, originally developed for type 2 diabetes mellitus, have demonstrated in randomized trials a significant reduction in hospitalizations and cardiovascular mortality, with benefits extending to non-diabetic patients. SGLT2 inhibitorsTheir mechanism combines moderate osmotic natriuresis, selective reduction of extracellular volume, renal protection, and minimal neurohormonal activation. In contrast to loop diuretics, which induce rapid volume depletion and RAAS activation, SGLT2i stabilize sodium-water balance without significant hemodynamic compromise. In clinical practice, their combination with diuretics requires careful titration to prevent hypovolemia, hypotension, and renal dysfunction, especially in frail elderly patients. Evidence suggests that SGLT2i may reduce chronic diuretic requirements, improve renal function, and provide additional cardiovascular protection. These findings support their early and integrated use, positioning SGLT2i as a cornerstone in the contemporary management of heart failure.