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

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.

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.