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

Introduction. Home hemodialysis is an effective therapeutic option for patients with chronic kidney disease. As highlighted in the literature, its management requires good self-care abilities from the patient and adequate support for self-care from the caregiver. Therefore, the development of educational programs plays a fundamental role in patient care. Aim. The goal of this study is to map the educational programs aimed at caregivers and patients undergoing home hemodialysis treatment, in order to identify gaps in the literature regarding this focus. Methods. A Scoping Review was conducted following the Joanna Briggs Institute guidelines. Potentially relevant articles were identified through a selection process on major databases (PubMed, Scopus, CINAHL, EMBASE, Web of Science, and Google Scholar), without applying any time limits. Results. The educational programs available in the literature for home hemodialysis patients focus on both clinical and psychological aspects; training through a "practical" approach is the most commonly used strategy. Discussion and conclusions. The review highlights the crucial role that a multidisciplinary and multidimensional educational approach can provide to home hemodialysis patients. It is necessary to optimize educational strategies for this population to improve patient outcomes.

The renal transplant scenario has changed profoundly in the last two decades in both the typology of donors and recipients. This phenomenon has not been accompanied by a significant renewal of the therapeutic arsenal in maintenance therapy, which needs to be more versatile and adapted to the new needs of personalized therapy. Compared to traditional drugs, the only concrete innovation is represented by lymphocyte costimulation inhibitors whose progenitor, and for now the only representative in current practice, is Belatacept with characteristics of absent nephrotoxicity and metabolic impact on dyslipidemia and glucose metabolism, and greater prevention compared to calcineurin inhibitors (CNIs) in the development of donor-specific antibodies. Data from randomized clinical trials clearly indicate a significant long-term GFR gain compared to CNIs. The risk of acute rejections post-conversion to Belatacept is averted by more recent imbrication protocols with CNI. The association with mTOR inhibitors appears promising, allowing us to exploit some peculiar characteristics of this class. In conclusion, new maintenance immunosuppressive regimens may benefit from the synergy of established drugs with belatacept possessing unique characteristics.

The technique of dialysis has seen enormous advancements over the past fifty years, evolving from an initial phase, primarily based on diffusion through a semipermeable membrane to the current preference for high-efficiency convection, involving the removal of several liters of ultrafiltrate. Diffusive dialysis, due to its relative simplicity in execution, has allowed the treatment of millions of individuals with ESRD, ensuring them a certain quality of life. However, it is not considered optimal in terms of survival and has some complications inherent to the uremic state. Convection, by removing toxic substances through solvent drag, has enabled the purification of not only small molecules but also medium-to-large molecular weight molecules. As a result, hemodiafiltration techniques have shown improvements in both mortality and intradialytic complications such as cramps and intradialytic hypotension. These results, however, involve fluid exchanges that far exceed 20 liters per session, thus increasing technical complexity and not being applicable to all patients, particularly those with vascular access problems. The recent discovery of so-called medium cut-off (MCO) membranes appears to maintain the benefits of hemodiafiltration techniques without the need for high convective flows. Therefore, the debate between convection and diffusion seems far from over and may hold more surprises in the near future.

Chronic Kidney Disease (CKD) provokes biochemical and systemic alterations, causing bone fragility with an increase in bone fracture risk, extraskeletal calcifications, increased morbidity, and cardiovascular mortality. The complex pathophysiological mechanism causes a syndrome called CKD-MBD (Chronic Kidney Disease - Mineral and Bone Disorders), which includes mineral and bone alterations leading to renal osteodystrophy (ROD). An early diagnosis is therefore essential to prevent the onset of more severe complications. A precise diagnosis of bone disorders and the subsequent administration of the best therapy is difficult without performing a bone biopsy. However, lately, the diagnostic focus is shifting to a series of molecules, the bone turnover markers (BTM), generated by the same bone tissue during the remodeling process, which is proving to be a useful diagnostic tool in the definition of ROD. BTMs are divided into bone formation molecules (amino-terminal propeptide of type 1 procollagen, P1NP; osteocalcin, OC; bone alkaline phosphatase, bALP) and bone resorption molecules (carboxy-terminal cross-linked telopeptide of type 1 collagen, CTX; isoform 5b tartrate-resistant acid phosphatase, TRAP-5b). There are also biomarkers of bone metabolism such as parathyroid hormone (PTH), fibroblast growth factor 23 (FGF23), and sclerostin. Although PTH is one of the most used molecules, P1NP, bALP, CTX, and TRAP-5b have proven to be superior in the discrimination of low turnover pathologies. The diagnostic capability of these molecules and their potential still require further studies, but clinicians must include BTMs in the diagnostic process of CKD-MBD.

Anaemia is a frequent complication of chronic kidney disease; if severe and untreated, it leads to a worsening of quality of life and an increased risk of resorting to haemotransfusions. Beginning with studies in physio-pathology that began in the late 19th century and continued into the 20th century, the first step was the identification of erythropoietin, then its purification, identification of the gene involved and finally the synthesis of recombinant human erythropoietin and its 'long-acting' analogues. Today, therapy with erythropoiesis-stimulating agents (ESAs), often in combination with martial therapy, is the standard of care for patients with chronic kidney disease and anaemia. Recently, ESAs have been joined by HIF-PHD inhibitors. Unfortunately, both categories of drugs, although effective and well-tolerated in most cases, may be associated with a possible increased cardiovascular and thrombotic risk, especially in particular categories of patients. For this reason, the choice of therapy with ESA and HIF-PHD must be customised in terms of haemoglobin target, molecule type and dosage to be used.

Among the recent advancements in Peritoneal Dialysis, the guidelines on the prevention and treatment of peritonitis, published in March 2022 by the International Society for Peritoneal Dialysis (ISPD), are of particular importance. The ISPD periodically updates these guidelines, with the previous update dating back to 2016. Peritonitis, despite its decreased incidence, remains a significant challenge in PD as it continues to be a major cause of morbidity, mortality, and dropout from the modality. The 2022 ISPD guidelines update the previous recommendations and introduce new ones. These recommendations are evidence-based where evidence is available.

Numerous studies have shown that hyperuricemia (HU) is an independent risk factor for the development of chronic kidney disease (CKD) and cardiovascular events. However, while some evidence suggests that uric acid (UA) may play not only a predictive but also a causal role in these conditions, a robust and definitive demonstration of this is still lacking. Moreover, despite what appears to be a logical rationale supporting the use of so-called 'urate-lowering therapy' (ULT) for nephroprotection in hyperuricemic patients with CKD, studies and meta-analyses on this topic - sometimes burdened by limitations that may have affected their results - have so far provided highly divergent outcomes, leaving uncertainty about whether drug-induced reduction of uricemia can truly slow the progression of CKD and prevent its cardiovascular complications. This article summarizes current knowledge on UA metabolism and the drugs that interfere with it, discusses theories on the possible multiple pathogenic mechanisms underlying HU related kidney damage, and reviews the results and limitations of the most recent studies that have supported or refuted the nephroprotective role of ULT in CKD, fueling an ongoing scientific controversy.

Iron therapy in nephropathic patients can allow optimizing treatment with EPO identifying the minimum effective dose capable of improving the patient's quality of life. The most recent studies on iron metabolism and on the interference of iron deficiency syndrome on the performance of some organs, in particular the myocardium, suggest the need to intervene very early, especially in patients with cardiomyopathy and systolic deficit. Setting up an iron therapy in nephropathic patients requires a correct diagnosis. That is particularly difficult in comorbid and inflamed patients because of the poor diagnostic reliability of the main biomarkers (ferritin and transferrin saturation). We need to spread the use of biomarkers that are not influenced by the inflammatory state, not expensive and easily accessible: reticulocyte hemoglobin could meet these requirements. The Pivotal study has delineated the optimal iron treatment in incident hemodialysis patients, treated with EPO not inflamed with classical biomarkers. It is yet to be determined, however, whether the Pivotal results are reproducible in more comorbid patients, also considering new and different therapeutic scenarios that the use of hypoxia-inducible factor-prolyl hydroxyl inhibitors may determine.

The renin-angiotensin-aldosterone (RAAS) system plays a significant role in renal and cardiovascular pathophysiology, since its increased activity is involved in arterial hypertension, heart failure, and kidney disease. ACEIs and ARBs are essential drugs for nephroprotection: they reduce blood pressure values and albuminuria, both related to cardiovascular damage and CKD progression. The nephroprotective effects are evident in both diabetes mellitus and non-diabetic renal disease, and the initial eGFR fall, if not more than 30%, should be considered as a marker of long-term success of renal protection. To optimize the RAAS inhibition salt intake should be strictly controlled, moreover the effective antiproteinuric dose can often be higher than that used as an antihypertensive. In selected and closely monitored cases, it is also possible to consider dual RAAS blockade. Finally, it should be noted that in patients with advanced CKD RAAS inhibition should not be discontinued, either because it does not give any benefit on GFR or because it increases cardiovascular risk.