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

Introduction. Acute Kidney Injury (AKI) is a serious complication in critically ill patients associated with significant morbidity and mortality. Early detection and risk stratification remain challenging, particularly in complex conditions such as septic shock where hemodynamic alterations complicate the clinical picture. Renal Resistive Index (RRI), measured through Doppler ultrasonography, has emerged as a promising non-invasive tool for assessing renal hemodynamics and microcirculatory changes. While various studies have investigated the relationship between RRI and AKI, there has not been a comprehensive systematic evaluation of RRI's utility in predicting and assessing AKI in critical care settings. Objective. The main aim is to evaluate the difference in RRI between patients who manifested AKI and patients who did not manifest AKI. Furthermore, the risk of AKI occurrence related to RRI will be computed. Methods. We will perform systematic research in PubMed and Scopus according to the PRISMA Guidelines. We will screen observational studies, with both retrospective and prospective designs on critically ill patients, without sex or age restriction. Expected results. This systematic review is expected to provide a comprehensive and extensive evaluation of the relationship between RRI and AKI. It will be based on observational studies, as RRI is a risk factor not subject to control by the investigator. In addition to assessing the association between RRI and AKI, the study also aims to highlight potential gaps in current knowledge and suggest directions for future research. Conclusions. The present systematic review protocol will include all existing evidence from published articles evaluating the RRI values in patients manifesting or not AKI.

The measurement of glomerular filtration rate (GFR) is essential in diagnosing and managing chronic kidney disease (CKD) and autosomal dominant polycystic kidney disease (ADPKD), both requiring precise renal function assessment. Traditionally, GFR has been estimated using endogenous markers like creatinine and cystatin C, though these can be inaccurate due to factors unrelated to kidney function, such as muscle mass and diet. The iohexol clearance method provides a more accurate and less invasive alternative to traditional markers like inulin or radioactive markers. Iohexol, a non-ionic, water-soluble contrast agent, is exclusively eliminated by glomerular filtration, making it highly suitable for direct GFR estimation. This paper describes procedures for iohexol clearance, involving defined-interval blood samples after intravenous administration. In patients with normal renal function, sampling intervals are more frequent, while in advanced CKD patients, including those with ADPKD, slower iohexol elimination requires wider intervals to ensure accurate clearance analysis. Iohexol has demonstrated high precision and reproducibility, even compared to other markers. Research supports using iohexol to monitor CKD and ADPKD progression effectively. Particularly in ADPKD, iohexol detects subtle but clinically significant GFR changes, even in early disease stages, making it valuable for evaluating targeted therapies. However, iohexol use is limited to specialized centers due to high costs and strict protocols. Its implementation in advanced European healthcare facilities underscores its efficacy, providing reliable GFR estimates that enhance nephrology practice, despite some limitations.

ADPKD is the most common inherited kidney disorder, marked by numerous renal cysts, increased total kidney volume and progressive renal function decline. Mutations in the PKD1 and PKD2 genes, leading to altered cAMP signaling, drive cyst growth. Elevated antidiuretic hormone (ADH) levels further exacerbate cystogenesis. Tolvaptan, a vasopressin V2 receptor antagonist, is the only approved treatment for slowing ADPKD progression, but its use often results in significant polyuria and thirst, affecting patient quality of life. This case report presents a 31-year-old female with ADPKD, classified as Mayo Class 1D, who showed improved tolerance to tolvaptan after co-administering low-dose hydrochlorothiazide (HCT). The patient experienced a significant reduction in polyuria and thirst while maintaining stable kidney function over four years. The annual decline in eGFR was less than expected for her disease class and improved compared to the first year of tolvaptan therapy. This case suggests that HCT may enhance tolvaptan tolerability without reducing its efficacy. Ongoing studies, such as the HYDRO-PROTECT trial, aim to further explore the benefits of combining HCT with tolvaptan in ADPKD management.

Background. Acute kidney injury (AKI) is a common and serious complication in patients with decompensated liver disease (DLD), often resulting from ischemic acute tubular necrosis or hepatorenal syndrome. This study examines the role of biochemical markers and ultrasound parameters, such as right atrial pressure, right ventricular hypertrophy, inferior vena cava diameter, hepatic venous flow dynamics, left ventricular diastolic dysfunction, the E/e' ratio, renal peak systolic velocity, renal end-diastolic velocity, and renal resistive index (RI), in predicting AKI severity and outcomes. Methods. A prospective observational study was conducted on 50 DLD patients with AKI, admitted to a tertiary care Hospital. Biochemical parameters including serum creatinine, bilirubin, and albumin along with ultrasound parameters were assessed. AKI was classified according to KDIGO criteria, and renal recovery and mortality were monitored. Diagnostic accuracy was evaluated through ROC analysis. Results. 30% of patients had stage 3 AKI, with 60% of them being male (average age 54 ± 12 years). Stage 3 AKI was a significant predictor of mortality (OR 3.5, p < 0.001), along with renal resistive index (OR 2.8, p = 0.003). ROC analysis showed that serum creatinine and the E/e' ratio, along with the RI, were significant predictors for AKI severity and mortality. Renal recovery occurred in 58%. Conclusion. The simultaneous assessment of clinical, biochemical, and ultrasound parameters enhances the prediction of AKI severity and patient outcomes in DLD. This approach facilitates earlier detection and better management of AKI in this population.

The success of peritoneal dialysis (PD) relies imperatively on the presence of a safe and well-functioning peritoneal access. The ideal catheter should be easy to position and durable, comfortable and practical to use, have minimal aesthetic impact and present low infectious and mechanical complications. Originally, the catheter that came closest to these characteristics was designed by Tenckhoff at the end of the 1960s. Over the next fifty years, different types of devices were developed with the aim of improving their efficiency and at the same time reducing the associated complications. Overall, none of these catheters has demonstrated a clear superiority over the Tenckhoff catheter and yet up to 30% of PD discontinuations are due to access-related complications. However, nowadays the wide range of existing models bestow the possibility of a personalized choice. This approach, together with the placement technique and the experience of the centre, would allow maximizing the benefits deriving from specific features of the PD catheter in relation to peculiar conditions of the recipient. Therefore, for clinicians involved in the positioning and care of peritoneal access, understanding the principles underlying the different configurations of the PD catheter is necessary to establish a "case by case" approach.

The cloudy bag in peritoneal dialysis is generally associated with infectious peritonitis and non-infectious etiologies. These cloudy bags may have increased cellularity or low/acellular counts. In the case of low cell count, the concomitant detection of fibrin or fat can provide guidance on its etiology. The cloudy peritoneal bag with a whitish appearance is usually due to its high fat content (chyloperitoneum). The etiologies include pharmacological, traumatic or inflammatory causes. The elevated fatty component in chyloperitoneum may be triglycerides (chylous), cholesterol (pseudochylous) or lymph. We present the case of a patient with stage 5 chronic kidney disease (CKD). He starts continuous ambulatory peritoneal dialysis and presents turbid but acellular peritoneal effluent with chylous appearance, negative cultures, and low levels of triglycerides and cholesterol on physicochemical evaluation. It doesn't meet the criteria for chylous or pseudochylous fluid, which is why the term lymphoid fluid is here proposed to describe it, because of its resemblance to lymphatic fluid in color. To our knowledge, this is the first case in the literature to report this effluent (milky-looking fluid without high levels of triglycerides or cholesterol) and to propose a specific term to describe it.

Background. Effective collaboration between general practitioners (GPs) and nephrologists is crucial for optimizing the management of chronic kidney disease (CKD). The TOSCA-CKD project (Treatment Optimization and Standard of Care Adherence in CKD Primary Care) aimed to evaluate the implementation of guidelines and the use of nephroprotective therapies in primary care. Methods. Clinical data were collected from the medical records of GPs across 12 Italian regions. The data were analyzed at baseline (T0) and after 6 months (T6) of collaboration with nephrologists. During this observational period, GPs were involved in remote education programs, which included expert-led webinars and clinical case-based learning. Results. A total of 76 GPs and 9 nephrologists were involved in the study, evaluating a cohort of 124,759 patients. There was an increase of 23.3% in the uACR test from T0 to T6 (3.0% vs. 3.7%; p < 0.001). Similarly, there was an increase of 15.2% in the use of eGFR from T0 to T6 (29.7% vs. 34.2%; p < 0.001). The rate of CKD diagnosis increased by 17.5% among patients with eGFR < 60 mL/min/1.73 m² (from 4% to 4.7%) and by 40% among patients with ACR > 30 mg/g (from 0.5% to 0.7%). The use of ACEi/ARBs remained stable at approximately 50%, while the treatment with SGLT2i, the new standard of care according to the current CKD guidelines, increased by 29.8% (from 4.7% to 6.1%). Conclusions. The TOSCA-CKD project demonstrated that GPs' remote educational program and a structured co-management approach significantly enhanced the early identification and improved the management of CKD in primary care.

Infections related to the peritoneal catheter, whether of the exit-site or of the subcutaneous tunnel (ESI), are a predisposing factor for the development of peritonitis. The regions of Friuli-Venezia Giulia, Trentino-Alto Adige and Veneto (Triveneto) have started a collaborative network to spread knowledge and optimize the use of peritoneal dialysis. The need to collect and aggregate ESI data emerged, therefore the project of a Register of ESIs of the Triveneto (RESIsT) was launched. This work analyzes the preparation and testing phase of the Registry.

Alport syndrome is a hereditary disorder characterized by hematuria, proteinuria and progressive renal failure, frequently associated with extrarenal manifestations. The pathogenic variants of the COL4A5 gene are associated with X-linked Alport syndrome while those of the COL4A3 and COL4A4 genes are associated with the autosomal recessive (AR) or dominant (AD) form. The disease is characterized by considerable phenotypic variability linked to the different genes involved and the different mutations present, so the symptoms manifest themselves in different frequencies depending on the case. The existence of an autosomal dominant form of Alport syndrome has been identified in recent years thanks to next generation gene sequencing (NGS) techniques which have made it possible to highlight unknown genetic variants of Alport syndrome. The family studied by us presents concomitant heterozygous alterations of the COL4A3 genes (c.1029+5G>A with MAF 0 and c.3211-7A>G with MAF 1:100000), heterozygous alterations of the MTHFR gene (both C677T and A1298C) and homozygous alteration of the PAI-1 gene. While the variant c.3211-7A>G, as shown by genetic databases (ClinVar), appears to be benign, the intronic variant c.1029+5G>A (caused by exon skipping) can be classified as pathogenic due to its characteristics and the fact that it co-segregates with the phenotype within the family. The histological data, in one of the sisters, highlighted the presence of a discrete global glomerular sclerosis and the ultrastructural investigation a thinning of the glomerular basement membrane. New mutational variants of the COL4A3 gene may play a role as risk variants for the development of chronic kidney disease.

Gout is a common, complex, systemic and well-studied form of chronic inflammatory arthritis due to deposition of sodium monourate crystals in peripheral joints and periarticular tissues driven by hyperuricemia. Gout is the oldest recorded inflammatory arthritis to affect humankind, with roots stretching back to 2640 BCE. To establish the timeline of gout from the Corpus Hippocraticum to the Renaissance, this study focuses on Galen (129-c.215 CE). A princeps English edition of Galen's works is still lacking; therefore, this paper provides a translation of the paragraph on gout from the Latin edition [12] by Carolus Gottlob Kühn (Leipzig, 1821-1833). Galen departs from Hippocrates and displays a vast knowledge of pathogenesis, symptomatology, clinical course, differential diagnosis, therapeutic skills and prognostication. In Galen's view, gout is due to fluid overflow that infiltrates nerves and causes pain. Overflowing fluid may be blood, phlegm, or a mixture of bile, blood, and phlegm. The prevailing humor is crude, mucous, and thick, and by residing in the joint, causes tophi. The nature of infiltrating humor can be diagnosed through color of the joint, symptoms, effects of heat and cold, effects of drugs, and information related to age, diet, quantity and quality of exercise, attitude towards baths of the patient. Treatment, according to Galen, required immediate bloodletting by venesection at the elbow, which could be repeated. Purges, enemas, and/or emetics are additionally needed to evacuate the humor(s). Poultices played a role draining the humor(s) as well as for their emollient-softening properties.