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Depression in patients affected by renal disease is a relevant problem because it is related to a increase of death and hospitalization rate and to a reduction of compliance. The pharmacological treatments result to be the best therapy of choice, however there is a greater difficulty in treating depressive symptoms that occur in comorbidity with renal disease, than when depression is the only disease. Various studies show that this problem can be addressed through an integrated pharmacological and psychotherapeutic intervention, which presents an additive effect in the treatment of this pathology. In relation to renal disease various studies suggest the effectiveness of psychotherapeutic intervention in the treatment of depressive symptoms, but more research is needed to compare the effectiveness of the different psychotherapeutic approaches.

Cardio-renal syndrome is well – known clinical syndrome, describing both negative effects of impaired renal function on heart and circulation and, on the other hand, those of heart failure on renal function.Many author have investigated the usefulness of serological markers in identify and eventually follow this syndrome. Natriuretic peptides levels are not only directly associated with severity of heart failure, but on the other hand they can help to detect renal dysfunction before creatinine serum levels raise up.NGAL, Cystatin C, NAG, KIM-1 and IL-18 represent interesting biomarkers for early detection of acute kidney injury (AKI), while urinary KIM-1 and urinary IL-18 seems to be appropriate only for differential diagnosis of established AKI.

Fungal peritonitis represents an infectious life-threatening complication in chronic kidney disease patients on peritoneal dialysis (PD). It causes more than 25% mortality rates (1, 2) often leading to patients' drop out from PD, Tenckhoff catheter removal and hospitalization. Causative diagnosis is often delayed because of non-specific clinical signs and symptoms in respect of bacterial infections and slow mycotic spores growth in coltures. Catheter removal is quickly recommended after microbiological or cultural mycotic identification based on International Society for Peritoneal Dialysis Guidelines/Recommendation 2010 update (3). Furthermore, international guidelines provide only few specific hints about drug choice, dosage, combination and length of antimycotic therapy; we must treat our patients for weeks or months most often.Our clinical report refers to a 70 years old woman, on APD (Automated Peritoneal Dialysis), who developed a fungal peritonitis by Aspergillus niger. Tenckhoff catheter was immediately removed and voriconazole intravenous treatment promptly started with consequent clinical improvement and complete recovery.

Chronic hemodialysis requires an efficient vascular access which is fundamental for a good dialytic efficiency. The native arteriovenous fistula is preferred for its longer survival and lower infection rates. In case of patients with inadequate vessels, synthetic grafts may be created. Periodic monitoring of vascular access with duplex ultrasound has been demonstrated to be able to identify early access dysfunction, thus anticipating surgical intervention and improving its long-term survival. Nevertheless, the need for a systematic monitoring of vascular access with ultrasonography is still debated.

Chronic nephropathic patients often present morphological and functional alterations of the gastro-enteric apparatus. Gastrointestinal diseases represent the most common and early signs. PPIs presented for many decades an important inhibitory effect on gastric acid secretion: they have a common chemical structure, a common mechanism of action and they are very important for treating acid-related pathologies, for Helicobacter Pylori eradication, for preventing and curing NSAIDs gastropathies. We prescribe this class of drugs to our patients even after the pathology resolution (gastroprotection). However can PPIs be indiscriminately used with chronic nephropathic patients or is it necessary to know the drug profile, in order to make a better choice? In this paper we argue that collateral effects are not very relevant and that they are very similar: their long-term usage is very safe. Power and efficacy of the different PPIs results very similar on the basis of how many milligrams of substance has been used and on the basis of clinical trials. The only exception that is shown in this paper is represented by 6 haemodialysis patients, which have been treated with lansoprazol (15 mgs). They presented gastritis and peptic ulcers, which were complicated by episodes of severe hematemesis and melena, with a consequent anaemia. Even though all PPIs have shown a similar clinical efficacy it is important to evaluate from time to time the (relative) advantages of each PPI. Criteria for a correct choice should be based mainly on official indications, on available doses and on the safety of the drug.

Urinary tract infections are a frequent clinical problem in all ages. Ultrasound is a valuable tool in the diagnosis and management of infections, allowing you to quickly diagnose complications and predisposing factors.This review provides an overview of the principal sonographic pictures during infections of bladder, prostate, seminal vesicles, testicles, epididymis and scrotum, providing a handy quick reference tool to the nephrologist interested in ultrasonography.

Kidney is mainly involved in fluid and electrolytes homeostasis, as well as in toxins knockout. Kidney function seems to be strictly related to heart and cardiovascular asset and ‘cardiorenal syndrome’ is now used to identify clinical correlation between heart and kidney disease. Chronic heart failure (CHF) represent first cause of hospitalization in western countries; CHF patients often present with mild to severe chronic kidney disease (CKD). Many physiological and pathophysiological pathways are postulated to explain how CKD can affect CHF prognosis and vice-versa. cGMP and NO - cGMP axis could be involved in pathogenesis of CHF in CKD patients together with natriuretic peptides (ANP and BNP) and phosphodiesterases control.Patients with CHF need to be treated for their chronic volume overload. First choice therapy is undoubtedly diuretic therapy, often with association between different kinds of drugs (such as thiazides and loop diuretics). Ultrafiltration excorporeal treatments are usually indicated in those patients not responding to massive diuretic treatments and they are often employed as complementary treatment in patients with refractory CHF.

Nephroangiosclerotic chronic kidney disease's primary and secondary prevention is actually based on blood pressure control and reduction of proteinuria. In proteinuric patients, blood pressure control has to be obtained by blocking renin–angiotensin axis, even in patients with moderate to severe chronic kidney disease. Combination therapy with angiotensin converting enzyme inhibitor (ACEi) drugs and angiotensin II receptor blockers (ARB) doesn't imply addictive protective effects. It could be tested in selected patients with proteinuria levels above 1 g/day. Combination therapy with ACEi and anti–aldosteronic agents seems to be promising but we need more multicentric trials.

Aim The purpose of the study was to examine the effect of hemodiafiltration with endogenous reinfusion (HFR) compared to hemodialysis (HD) on 28 uremic patients with secondary hyperparathyroidism (2HPT) but positively selected for good and stable control of phosphatemia in order to evaluate the independent effects of dialysis treatments on bone turnover metabolism. Methods: The study was divided into 3 periods of observation: a) HD for three months; b) HFR for three months; c) HFR for a further 3 months. We analysed the trend of: whole PTH, 1–84 PTH, 7–84 PTH, alkaline phosphatase and its bone isoenzyme, total and ionised calcium, phosphatemia, dose of phosphate binder agents, ß2-microglobulin, CRP. All the variations found were evaluated through mean values ± SD, t-tests, multivariate analysis.Results We observed a deceleration in bone turnover characterized by a reduction of the total and bone alkaline phosphatase (IU/mL) from 92.3 ± 82.8 and 35.8 ± 49.8 at the end of HD to 63.4 ± 23.9 and 16.0 ± 8.7 at the end of HFR, respectively, and 1–84 PTH from 317.5 ± 264.6 pg/mL at the end of HD to 287.5 ± 258.9 pg/mL at the end of the 3rdmonth of HFR. ß2-microglobulin was reduced from 32.9 ± 16.1 mg/L at the end of HD to 26.4 ± 8.1 mg/L already at the end of the first three months of HFR. CRP was reduced from 2.5 ± 2.6 mg/dL at the beginning of the study to 1.3 ± 1.7 mg/dL at the end of HFR. There were no differences with regard to: dialytic efficiency, nutritional status, calcemia, phosphatemia (maintained in the K-DOQI range for the entire duration of the study), also thanks to more careful use of phosphate chelating agents.Conclusion We are of the opinion that HFR - essentially thanks to the use of ultrapure endogenous infusate - induces a deceleration in bone turnover due to 2PHT. In addition, phosphate substraction in HFR is better compared to HD, thanks to the improvement of the anti-inflammatory conditions by removing the cytokines harmful to bone metabolism and excluding a priori the negative effects related to hyperphosphatemia. (Int J Artif Organs 2006; 29: 1042–52)

Vascular access (VA) for hemodialysis (HD) is one of the most important clinical problems in end-stage renal disease (ESRD) patients because it can limit a life support system and can influence long-term dialysis patient survival. Nevertheless, VA becomes useless after a successful renal transplant. Therefore, we wanted to evaluate the natural history of arteriovenous fistulas (AVF) in renal transplanted patients and the possibility of maintaining the fistula as patent or not.Methods A retrospective study was conducted to evaluate kidney transplant patients in our unit from April 1994 to April 2004. We studied 542 patients.Results There were 365 patients with a well functioning kidney. Eighty-six patients died. Ninety-one patients were put back on dialysis: 89 patients on HD and two patients on CAPD. Of the 365 patients with functioning kidney transplants, 198 patients demonstrated a patent fistula, while 167 patients had a closed fistula. One hundred and twenty-five patients had a spontaneous closure and 42 patients had a surgical closure. Of the 89 patients put back on dialysis, 49 patients used the previous AVF, while it was necessary to create a new VA in 40 patients.Conclusions As demonstrated by the results of our study, after renal transplantation the possibility of spontaneous AVF closure caused by a thrombosis is not a rare event. The dilemma is whether to preserve a fistula that could be useful in case of restarting HD or to perform a systematic fistula closure because of cardiac output and cardiac failure risks. Concerning this question there is no consensus between different authors in the literature. In reviewing the literature and analyzing our data, we conclude that the definite indications for AVF closure in well functioning renal transplanted patients are heart failure, high flow fistula, VA complications and important aesthetic reasons. Routine AVF closure is not indicated until prospective and randomized studies can demonstrate the ability of this procedure to reduce the high incidence of cardiac morbidity and mortality that is present, even after renal transplantation.

Cannulation of central veins and placement of catheters for temporary haemodialysis is a common procedure in the management of patients with end stage renal failure. The internal jugular vein is the site of choice for central venous catheter placement, being associated with the lowest complication rate. This procedure can be associated with a variety of malpositions of the catheter and rarely, can lead to significant morbidity and even mortality, if this is not recognised and corrected early. For anatomical reasons, the risk of azygos arch cannulation is substantially increased if catheters are inserted via left-sided veins. We report a case with a rare complication associated with the insertion of a catheter for temporary haemodialysis.