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The KDOQI guidelines (Kidney Disease Outcomes Quality Initiative) recommend autologous arteriovenous fistula (AVF) as the primary vascular access in hemodialysis patients because of the higher quality of life and lower complication rates if compared to arteriovenous grafts (AVGs) or central venous catheter (CVC). Several studies used various inflammatory biomarkers to evaluate the association between systemic inflammation and AVF dysfunction. A novel inflammatory biomarker, the platelet-lymphocyte ratio (PLR), is a useful and easy laboratory parameter that can reveal systemic inflammation. Our study aimed to evaluate the relationship between PLR value changes over time and AVF dysfunction. The impact of PLR on our outcome showed a trend close to the significance (OR: 4,9; 95%CI: [0.84-28.5]; p = 0.08) but the slope was not linear. Therefore, we performed the same analysis splitting the patients by the median PLR value and we highlighted a significant relationship between our outcome and the PLR (log-transformed) for PLR-value under the median value (OR: 9.97; 95%CI: [2.53-39.25]; p = 0.001). Furthermore, in patients with PLR above the median value, the interaction visit-PLR showed an impact close to the statistical significance (OR: 7.7; 95%CI: [0.81-72.97]; p = 0.07). PLR (log-transformed) was positively correlated with AVF age (Rho: 0.254, p = 0.002)., (Copyright by Società Italiana di Nefrologia SIN, Rome,Italy.)

Phosphorus is a macroelement found in the body, mostly in the bones as crystals of hydroxyapatite. Higher levels are found in patients affected by chronic kidney disease (CKD). Since the early stage of CKD phosphorous excretion is impaired, but the increase of PTH and FGF23 maintains its level in the normal range. In the last decades, the role of FGF23 in erythropoiesis was studied, and now it is well known for its role in anemia genesis in patients affected by conservative CKD. Both Hyperphosphatemia and anemia are two manifestations of CKD, but many studies showed a direct association between serum phosphorous and anemia. Phosphorus can be considered as the common point of more pathogenetic ways, independent of renal function: the overproduction of FGF23, the worsening of vascular disease, and the toxic impairment of erythropoiesis, including the induction of hemolysis., (Copyright by Società Italiana di Nefrologia SIN, Rome,Italy.)

Introduction. Patients undergoing chronic haemodialysis (HD) treatment have an 8-10 times higher risk of experiencing stroke events and developing cognitive impairment. The high vascular stress they are subjected to may be the basis for the development of vascular dementia (VaD). Objective. The aim of the study is to investigate the executive functions, typically impaired in VaD, of patients undergoing chronic haemodialysis treatment. Method. HD patients were recruited from the U.O.C. of Nephrology and Dialysis (ASP Ragusa). Risk factors for VaD were collected and then the Frontal Assessment Battery (FAB) was administered. Results. 103 HD patients were included (males = 63%, age 66 ± 14 years). Risk factors for VaD included a high percentage of patients with anaemia (93%), hypertension (64%) and coronary artery disease (68%). The cognitive data obtained via FAB show a percentage of 55% deficit scores. All risk factors found a significant association with cognitive scores. Anemia, hypertension, intradialytic hypotension, coronary artery disease, and homocysteine are negative predictors of executive function integrity. Conclusions. More than half of the patients had deficit scores on the FAB. Reduced cognitive flexibility, high sensitivity to interference, poor inhibitory control and impaired motor programming with the dominant hand were evident. In conclusion, a marked impairment of the executive functions, generally located in the frontal lobes of the brain, was detected in the HD patient, which could be a symptom of a dementia of a vascular nature., (Copyright by Società Italiana di Nefrologia SIN, Rome,Italy.)

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., (Copyright by Società Italiana di Nefrologia SIN, Rome,Italy.)

Introduction: Sleep disorders are very common in patients with chronic kidney disease, with a prevalence of poor sleep quality of around 40%. Objectives: The purpose of the study is to compare the sleep quality of ESRD patients before hemodialysis (Pre-HD), three months (Post-HD 1) and six months after the start of treatment (Post-HD 2) through the use of the Pittsburgh Sleep Quality Index (PSQI). Methods: Patients in ESRD were recruited from the U.O.C. of Nephrology and Dialysis of the Maggiore Hospital in Modica and biographical and anamnestic data were collected. The PSQI was administered in-person at the Pre-HD stage and by telephone re-test at the three- and six-month follow-up. Results: A total of 71 patients (males=62%, age 68 ± 16) were included. At Pre-HD assessment 93% reported poor sleep quality, the percentage increased to 98% during Post-HD 1 and it partially improved during Post-HD 2 with a prevalence of 95%. Analysis of variance (ANOVA) by repeated measures showed a difference in sleep quality between the three time points. Conclusions: Sleep quality undergoes important changes during the transition from conservative to hemodialysis patient, highlighting a critical period related to the first three months of treatment. More attention to this phase may improve the patient's quality of life and reduce the associated risk of mortality., (Copyright by Società Italiana di Nefrologia SIN, Rome,Italy.)

The increase in patients' average age, the enhancement of anticoagulation therapy and the growth of vascular interventions represent the perfect conditions for the onset of atheroembolic renal disease. AERD is observed in patients with diffuse atherosclerosis, generally after a triggering event such as surgery on the aorta, invasive procedures (angiography, catheterization of the left ventricle, coronary angioplasty) and anticoagulant or fibrinolytic therapy. The clinical signs are heterogeneous, a consequence of the occlusion of downstream small arterial vessels by cholesterol emboli coming from atheromatous plaques of the aorta, or one of its main branches. The proximity of the kidneys to the abdominal aorta, and the high flow of blood they receive, make them a major target organ. For this reason, AERD represents a pathological condition that always needs to be taken into account in the nephropathic patient, although its systemic nature makes the diagnosis difficult. This manuscript presents a review of the existing literature on this pathology, to provide an updated summary of the state of the art: risk factors, diagnostics, histology and therapeutic approaches., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The public emergency caused by Covid-19 has forced health services to reorganize in order to separate positive patients from negative ones. In nephrology, this reorganization involves several levels of assistance concerning hospitalizations, ambulatory care and haemodialysis. Within the Complex Unit of Nephrology in Ragusa, the distribution of nephro-dialytic resources has involved four different hospitals, hence ensuring haemodialysis services for asymptomatic and pauci-symptomatic Covid-19 patients as well as for patients in Covid-Unit, Sub-Intensive Therapy and Intensive Care Unit. In this complex context, we had to create a common protocol involving all the professionals who provide assistance in our Unit, across the different structures. We also report some encouraging data that seem to indicate the effectiveness of the protocols put in place., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Chronic kidney disease is associated with an increased cardiovascular risk. Several uremic toxins are also vascular toxins and may contribute to the increase of the cardiovascular risk through the development of aortic stiffening. In this process, oxidative stress and endothelial dysfunction play an important role. Considering that aortic stiffness is a known cardiovascular risk factor and a vascular biomarker involved in the development of chronic cardiac dysfunction, and that the reduction of aortic stiffness is associated with an improved survival of patients with end-stage kidney disease, we aim at reviewing the therapeutic options to reduce aortic stiffness and potentially the cardiovascular risk., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

In recent years imaging techniques that use radionuclides have become more and more clinically relevant as they can provide functional information for specific anatomical districts. This has also involved nephrology, where radionuclides are used to study patients with different degrees of renal function failure up to terminal uremia. Although chronic kidney disease, and dialysis in particular, may affect the distribution and the elimination of radiopharmaceuticals, to date there are no consistent data on the risks associated with their use in this clinical context. In addition to the lack of data on the safety of radio-exposure in dialysis patients, there is also a shortage of information concerning the risk for healthcare staff involved in conducting the dialysis sessions performed after a nuclear test. This study, performed on 29 uremic patients who underwent hemodialysis immediately after a scintigraphic examination, assessed the extent of radio-contamination of the staff and of hemodialysis devices such as monitor, kits and dialysate. The data collected has been used to quantify the radiological risk in dialysis after the exposure to the most common radionuclides., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The Cardiorenal Syndrome type 4 (CRS-4) defines a pathological condition in which a primary chronic kidney disease (CKD) leads to a chronic impairment of cardiac function. The pathophysiology of CRS-4 and the role of arterial stiffness remain only in part understood. Several uremic toxins, such as uric acid, phosphates, advanced glycation end-products, asymmetric dimethylarginine, and endothelin-1, are also vascular toxins. Their effect on the arterial wall may be direct or mediated by chronic inflammation and oxidative stress. Uremic toxins lead to endothelial dysfunction, intima-media thickening and arterial stiffening. In patients with CRS-4, the increased aortic stiffness results in an increase of cardiac workload and left ventricular hypertrophy whereas the loss of elasticity results in decreased coronary artery perfusion pressure during diastole and increased risk of myocardial infarction. Since the reduction of arterial stiffness is associated with an increased survival in patients with CKD, the understanding of the mechanisms that lead to arterial stiffening in patients with CRS4 may be useful to select potential approaches to improve their outcome. In this review we aim at discussing current understanding of the pathways that link uremic toxins, arterial stiffening and impaired cardiac function in patients with CRS-4., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Osteoporosis affects a segment of the population in which Chronic Kidney Disease is also greatly represented. Nephropathic patients may present peculiar biochemical abnormalities related to Chronic Kidney Disease, defining the Mineral and Bone Disorder. This kind of anomalies, in the worst scenarios, configure the typical histomorphology patterns of Renal Osteodystrophy. Scientific Societies of Endocrinology have established therapy guidelines for patients with osteoporosis only based on the glomerular filtration rate and recommend avoiding the use of some drugs for the more advanced classes of nephropathy. However, there is no clear therapeutic approach for patients with advanced nephropathy and bone abnormalities. In this paper we propose a systematic review of the literature and present our proposal for managing patients with advanced nephropathy, based on eGFR and on presence of Mineral and Bone Disorder., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

POEMS syndrome is a rare multisystemic disease characterised by the coexistence of two main symptoms, polyneuropathy and monoclonal gammopathy, associated with minor symptoms such as organomegaly, endocrinopathy, and skin changes. We describe a patient who presented with symptoms and signs fulfilling the criteria of POEMS. We have carried out a literature review with particular emphasis on its demographic and polymorphic clinical features., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Metformin is the first choice among drugs used for the treatment of type II diabetes mellitus mainly because of several advantages: proven hypoglycemic effect, good safety profile, virtually no risk of hypoglycemia, body weight reduction, lipid-lowering effect, efficacy in preventing micro- and macrovascular complications as well as adverse cardiac and cerebrovascular events and reduced cost. Previous reports had shown an increased risk of lactic acidosis in patients receiving metformin. However, the current Guidelines have greatly limited this risk to certain categories of patients, such as those with severe chronic renal failure, particularly when predisposing risk factors such as administration of iodinated contrast are present. In this review, we reported the main data of the literature on the use of metformin in patients with chronic renal failure and both highly expected benefits and high potential risks.

In contrast to other ions, magnesium is treated as an orphan by the body: there are no hormones that have a substantial role in regulating urinary magnesium excretion, and bone, the principal reservoir of magnesium, does not readily exchange with circulating magnesium.The Mg ++ is often overlooked by physicians in the differential diagnosis because it is considered insignificant, but its role is crucial for cells function, first of all neurons and cardiomyocytes. A condition of hypocalcemia associated with hypokalemia, especially in the presence of chronic renal failure, should raise suspicion of a lack of Mg ++.We report the case of an old man of 77 year with kidney transplant for 13 years, treated with cyclosporine, and sodium mycophenolate and steroid who, for about a month, accused impaired balance and walking instability, who fell accidentally down with wrist fracture.Blood tests showed hypocalcemia and hypokalemia, and so we required dosage of serum and urinary magnesium. A significant reduction in the ion plasma concentration was seen, associated to a fraction of excretion inappropriately high in relation to the degree of hypomagnesemia.The cause of this important renal loss is likely attributable to cyclosporine, a drug that has as a side effect the inhibition of the reabsorption of Mg ++ in the distal convoluted tubule. then, oral supplementation was started (244 mg of Mg ++ ion / day), with subsequent normalization, after a few days, not only of magnesiemia, but also in serum calcium and potassium levels, and improvement of neurological symptoms.Hypomagnesaemia is common in patients with renal transplantation in therapy with calcineurin inhibitors ICN, due to the effects of such drugs on the TRPM6 transporter present in the kidney distal convoluted tubule. To prevent complications caused by chronic and severe depletion of magnesium in this particular population, we recommend periodic monitoring of magnesium plasma levels.

Patients that are followed by nephrologists from the beginning of the illness, they show a deceleration in the progression of the Chronic Kidney Disease towards dialysis and a better quality of life (less osteodystrophy, anaemia and fluids overload, better pressure management). However, in 2013 it still exists a great lack of knowledge about the professional figure of nephrologist. Residents of Nephrological School of Catania decided to conduct a survey to evaluate common knowledge of renal diseases and their treatments. The survey was conducted in two cities of Sicily. The results show that people are generally uninformed and disoriented about renal illness and their risks.