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

Intravenous iodinated contrast media are commonly used in clinical practice, ranging from medical imaging to interventional radiology (IR) procedures and endovascular interventions. Compared with patients with normal renal function, nephropathic patients have an increased risk of acute kidney injury (AKI). Nevertheless, this condition cannot represent a limit to diagnostics or endovascular interventions. Despite the literature of the last five years, conflicting management and approaches for nephropathic patients persist, including the use of contrast agents and treatments replacing renal functions, which are often mistakenly considered as part of preventive strategies. Though the issue has been widely discussed, specialists often cope with uncertainty in handling properly the administration of contrast media and renal counselling requests. Furthermore, there is a general difficulty in distinguishing the Post-Contrast Acute Kidney Injury (PC-AKI) from the Contrast-Associated Acute Kidney Injury (CI-AKI). The present review aims to provide an update on the issue and examine strategies to reduce the acute kidney injury risk after the administration of contrast media. These strategies include the early identification of high-risk individuals, the choice of the contrast media and the proper dosage, the suspension of nephrotoxic drugs, the follow-up of the high-risk individuals, and the early identification of AKI.

Myeloma cast nephropathy is the most common cause of acute kidney injury in patients affected by multiple myeloma. The mainstay of management of cast nephropathy is the clone-based therapy by reducing production and thereby precipitation of light chains. Adjuvant therapy consists of inducing high urine volume flow and alkalinisation, where possible. Extracorporeal removal of light chains is still debated and the advantages of these procedures are not established. The use of safe and low expensive membranes may encourage their use and address their utility.

Cancer transmission from solid organ donors to recipients is a known risk factor in transplantation. The Italian National Network for Transplantation (CNT) has adopted specific guidelines to evaluate the suitability of donors with history of malignancy. CNT also provides a Second Opinion service to assess oncological cases with a potential risk of neoplastic transmission to the recipient. CNT aims to minimize the risk of disease transmission from donors to recipients. According to CNT guidelines, "standard" donors are defined as individuals with no signs of active malignancy and no history of cancer at the time of organ procurement. Unsuitable donors, defined as those with an "unacceptable risk", are those patients with evidence of malignancy at the time of donation or in their medical history that carries an unacceptably high risk of disease transmission. Between these two categories, a broad spectrum of "non-standard" donors exists, where the risk of transmission is not entirely absent, but remains low enough to consider organ utilization. Malignancy should not be considered an absolute contraindication for organ donation. CNT has also adopted a specific repository for adverse events (AE) after transplantation. Since 2012, with 10.493 donors and 34.193 performed transplants, 283 AE have been recorded, occurring in approximately 3% of donation processes and 1% of performed transplants. Oncological AE represented 13% of all reports. In the majority of cases, oncological AE resulted from missed diagnosis during organ procurement, benchwork, or transplantation surgery. CNT guidelines, the oncological second opinion service, and the repository helped minimize the risk of cancer transmission with transplantation.

A deadly embrace occurs between cancer and chronic kidney disease. The estimation of kidney function in cancer patients is of utmost interest due to its direct impact on chemotherapy dosing, selection, and eligibility for chemotherapeutics. Overestimating kidney function (determined as estimated glomerular filtration rate -eGFR) can lead to overdosing and drug toxicity, while underestimating kidney function can prevent patients from receiving novel therapies. Notably, the current measures of eGFR are not validated in transplanted patients yet. The field of onconephrology ranges from nephrotoxicity of existing and novel therapeutics, paraproteinemias, and cancer-associated electrolyte imbalance, fluid and acid-base disturbances, the effects of the destruction of cancer cells, and acute and/or chronic kidney injuries. Recently, the therapeutic armamentarium has been enriched with new agents that interfere with specific proteins involved in oncogenesis. These are the so-called target therapies, which although acquired as "targeted" therapies do not have absolute specificity and selectivity and tend to inhibit multiple targets, often involving the kidney. Renal biopsy may be critical in managing these adverse effects. Moreover, primary hematological and oncological disorders can have significant kidney implications in the form of glomerular or nonglomerular diseases presenting with proteinuria, hematuria, hypertension, and kidney function decline, specifically including cast nephropathy or systemic light chain amyloidosis, and paraneoplastic glomerulopathies that occur as a result of occult malignancy, such as Membranous Nephropathy and Minimal Change disease.

Onconephrology is a rising and rapidly expanding field of medicine in which nephrology and oncology meet each other. Besides multidisciplinary meetings, oncologists and nephrologists often discuss on timing of the treatment, dosage, and side effects management. Cancer patients often encounter different electrolyte disorders. They are mostly secondary to the tumor itself or consequences of its treatment. In the last years, the great efforts to find new therapies like targeted, immune, and cell-based led us to many new side effects. Hyponatremia, hypokalemia, hyperkalemia, hypercalcemia, and hypomagnesemia are among the most common electrolyte disorders. Data have shown a worse prognosis in patients with electrolytic imbalances. Additionally, they cause a delay in chemotherapy or even an interruption. It is important to diagnose promptly these complications and treat them. In this review, we provide a special focus on hyponatremia and its treatment as the most common electrolytes disorder in cancer patients, but also on newly described cases of hypo- and hyperkalemia and metabolic acidosis.

The incidence of tumors is increased in patients with chronic renal failure and even more in patients on dialysis. Dialysis can affect both therapy and prognosis of oncological patients. It increases both cancer-related and non-cancer-related mortality rates and is the main cause of a suboptimal use of therapies. In patients with renal impairment, the dosage of many chemotherapies should be reduced but, due to the lack of real knowledge of the pharmacokinetic and pharmacodynamic properties of these drugs in dialysis, dosage adjustments are often done empirically and most often avoided. Although many papers are available in the literature regarding chemotherapy in dialysis, there is a lack of consensus regarding drug dosages and administration schedules. Furthermore, guidelines are absent due to the lack of "evidence" for most of these patients, usually excluded from experimental treatments. Specific onconephrologic trials are therefore mandatory to decide how much, how, and when to use chemotherapy in patients on dialysis and thereby ensure adequate treatment for these patients.

Acute renal failure (AKI) is a high-prevalence complication in patients with cancer. The risk of AKI after cancer diagnosis is 18% in the first year, 27% in the fifth year, and 40% of critically ill patients with cancer require renal replacement therapy. The causes of AKI may be pre-renal due to hemodynamic problems, related to the cancer, metabolic complications, and drug or surgical treatment. One must preventively protect renal function by hydration, use of non-nephrotoxic drugs, correction of anemia, prevention of contrast agent-induced AKI (CI-AKI), and adjustment of cancer therapy in patients with CKD. It is essential to check basal renal function, creatinine trend, electrolytes, urinalysis and proteinuria, perform imaging, renal biopsy if necessary. The evaluation of patients should be multidisciplinary and timely including the initiation of renal replacement treatment (RRT). There are different modalities of replacement treatment depending on the clinical picture of the patient with AKI and cancer: intermittent hemodialysis (IHD), intermittent prolonged replacement therapy (PIRRT), and continuous replacement therapy (CRRT). The concept of dose administered, as opposed to prescribed dose, as well as the anticoagulation of extracorporeal circuits, which must be regional with citrate (RCA) as the first choice in the management of CRRT, turns out to be fundamental in order to achieve optimal circuit anticoagulation, with reduction of coagulation episodes and downtime, while maintaining the patient's coagulation status. The onco-nephrologic multidisciplinary approach is crucial to reduce the mortality rate, which is still high in this category of patients.

Onconephrology is a subspecialty of Nephrology with the aim of fully dealing with the complex and bidirectional relationship between the tumor and the kidneys. In a world where Nephrologists still too often consider Oncological patients as "lost" and in which Oncologists are afraid to administer oncological therapies to patients with renal failure due to the absence of Literature data, Onconephrology was created with the aim of guaranteeing patients with renal disease the same treatment opportunities as the general population. Over the years this subspecialty has developed and more nephrologists, experts in the field, daily support oncologists in clinical-therapeutic decisions by dealing with cases of renal toxicity from oncological therapy, managing treatments in patients with renal failure and dealing with all those conditions associated with both oncological and renal pathology in terms of prevention and treatment. In this paper we will retrace the history of Onconephrology by analyzing what are the results achieved and what are the objectives for the future.

Immunoglobulin Light Chain Amyloidosis (AL) is a progressive disease which leads to organ dysfunction and death. Tremendous progress has been made in staging, response, and treatment. The key to better survival though is early diagnosis which can be difficult since the symptoms are often nonspecific and can be seen in more common conditions. Once the diagnosis is confirmed, staging systems are available to provide prognosis on overall and renal survival. There are a number of treatments now available that are effective and well-tolerated. Response criteria have also been developed for hematologic and renal response in order to maximize response and minimize adverse effects. Newer therapies are being developed in particular anti-fibril therapies that are in clinical trials. For those patients who had a very good partial response or better, kidney transplantation may be an option if the kidney failure is not reversed.