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La glomerulonefrite membranosa rappresenta il 20% dei casi di sindrome nefrosica dell’adulto, con una incidenza annuale di 1/100.000 pazienti/anno. Negli ultimi 10 anni è stato identificato nel podocita il vero responsabile del processo patologico. In risposta a possibili triggers ambientali in pazienti geneticamente predisposti, il podocita espone epitopi antigenici (recettore della fosfolipasi A2, trombospondina tipo 1) che diventano bersaglio di autoanticorpi in grado di attivare il complemento e determinare danno della membrana basale glomerulare. Rimane incerto il meccanismo effettivamente patogenetico in queste complesse interazioni. Da queste acquisizioni sono derivati nuovi trattamenti focalizzati sui meccanismi specifici di blocco delle vie di attivazione della malattia con l’ipotesi di superamento dei farmaci convenzionali ad attività meno specifica. ll rituximab (Rtx), anticorpo monoclonale diretto contro il CD20 espresso dai linfociti B, è utilizzato in numerosi trials con lo scopo di bloccare la produzione di anticorpi. Il presupposto degli studi in corso deriva dal GEMRITUX trial, in cui Rtx si è dimostrato in grado di indurre remissione della sindrome nefrosica in circa il 65% dei pazienti senza un maggior rischio di eventi avversi; resta da definire lo schema terapeutico e posologico più efficace. Altri trials evidenziano nuovi orientamenti della ricerca su meccanismi di blocco specifico (belimumab) ed aspecifico (ACTH) e più occasionali segnalazioni prendono in considerazione nuove possibili opzioni terapeutiche quali l’ofatumumab, il bortezomib e l’eculizumab. Queste novità in campo patogenetico e terapeutico hanno determinato un impulso alla ricerca sui processi patologici implicati nella genesi delle nefropatie glomerulari ed avviato nuove prospettive di trattamento. The membranous nephropathy (MN) is the major cause of nephrotic syndrome in in the adult, account for 20% of cases with annual incidence is 1 in 100.000. In the past 10 years, the role of podocytes has been identified; environmental triggers in genetically predisposed patients can activate podocytes to exhibit antigenic epitopes (receptor of phospholipase A2, thrombospondin type 1) that become targets of specific autoantibodies with subsequent complement activation. The discovery of this mechanisms has opened new horizons in the therapy of MN and novel drugs are available with more specific mechanism of action. Rituximab, a monoclonal antibody directed against CD20 expressed by lymphocytes B, has been used in several trials and appears able to induce remission of nephrotic syndrome in 60% of patients (GEMRITUX trial) with similar risk profile. Nowadays it remains to define the most effective therapeutic pattern. In MN, the concept of targeting disease control, has permit novel therapies with specific blocking mechanisms (belimumab) and non-specific (ACTH) and new therapeutic options, such as ofatumumab, bortezomib and eculizumab, that have allowed to recognize pathological processes involved in the glomerular diseases.

Background and Objectives: Hemodialysis patients (HD) and kidney transplant recipients (KTRs) have been heavily impacted by COVID-19, showing increased risk of infection, worse clinical outcomes, and higher mortality rates than the general population. Although mass vaccination remains the most successful measure in counteracting the pandemic, less evidence is available on vaccine effectiveness in immunodepressed subjects previously infected and recovered from COVID-19. Materials and Methods: This study aimed at investigating the ability to develop an adequate antibody response after vaccination in a 2-dose series against SARS-CoV-2 in HD patients and KTR that was administered after laboratory and clinical recovery from COVID-19. Results: Comparing SARS-CoV-2 S1/S2 IgG levels measured before and after 2 doses of mRNA vaccine (BNT162b2 vaccine, Comirnaty, Pfizer–BioNTech or mRNA-1273 vaccine, Spikevax, Moderna), highly significant increases of antibody titers were observed. The antibody peak level was reached at 3 months following second dose administration, regardless of the underlying cause of immune depression and the time of pre-vaccine serology assessment after negativization. Conclusions: Our data indicate that HD patients and KTR exhibit a satisfying antibody response to a 2-dose series of mRNA vaccine, even in cases when infection-induced humoral immunity was poor or rapidly fading. Further studies are needed to evaluate the role of booster doses in conferring effective and durable protection in weak patient categories.

Background Following the positive experience of the national project “A transplant...and now it’s time for sport,” the Transplant Reference Center of the Emilia-Romagna Region has pursued the promotion of pre- and post-transplant physical exercise by developing a network. Methods The path involved the transplant centers and operative units (UU.OO) who wanted to target transplant and waiting list patients, who are clinically stable, to perform personalized exercise through a program (supervised or not) prescribed by a specialist in sports medicine. With the collaboration of the Collective Prevention and Public Health Service, the network was established, consisting of the sports medicine centers and the gyms that promote health for adapted physical activity (PS-AMA). To implement the network, training courses for all the professionals involved (doctors, nurses, exercise specialists) and operational meetings in the transplant centers-nephrology units with patients’ associations have been organized. Results To date, there are 14 transplant centers and UU.OO, 9 sports medicine centers, and 45 PS-AMA involved in this network. Seven training courses were organized with the participation of 193 health professionals. Since January 2016, there have been 65 transplanted patients and 5 patients on the waiting list who practice the prescribed exercise. Of these, 45 carry out supervised exercise in PS-AMA; 25 perform autonomous exercise. Each patient is monitored every 6 months. No problems related to the exercise performance were recorded. Conclusions The development of a network of professionals and associations is the key element to raise awareness of physical activity among transplanted and waiting-for-transplant patients, reducing the pathologies associated with a sedentary lifestyle.

none 11 no Background: Sodium prescription in patients with intradialytic hypotension remains a challenge for the attending nephrologist, as it increases dialysate conductivity in hypotension-prone patients, thereby adding to dietary sodium levels. Methods: New sodium prescription strategies are now available, including the use of a mathematical model to compute the sodium mass to be removed during dialysis as a physiological controller. Results: This review describes the sodium load of patients with end-stage renal disease on chronic hemodialysis (HD) and discusses 2 strategies to remove excess sodium in patients prone to intradialytic hypotension, namely, Profiled HD and the hemodiafiltration Aequilibrium System. Conclusion: The Profiled HD and Aequilibrium System trial both proved effective in counteracting intradialytic hypotension. mixed Donati, Gabriele; Ursino, Mauro; Spazzoli, Alessandra; Natali, Nicolã²; Schillaci, Roberto; Conte, Diletta; Angeletti, Andrea; Croci Chiocchini, Anna Laura; Capelli, Irene; Baraldi, Olga; La Manna, Gaetano Donati, Gabriele; Ursino, Mauro; Spazzoli, Alessandra; Natali, Nicolã²; Schillaci, Roberto; Conte, Diletta; Angeletti, Andrea; Croci Chiocchini, Anna Laura; Capelli, Irene; Baraldi, Olga; La Manna, Gaetano

Background: Immunoglobulin light chains are classified as middle molecule uremic toxins able to interact with B lymphocyte membranes leading to the activation of transmembrane signaling. The ensuing impairment of neutrophil function can contribute to the chronic inflammation state of uremic patients, and the increased risk of bacterial infections or vascular calcifications. The aim of this crossover observational study was to assess the difference in free light chain removal by three different hemodialysis filters in patients not affected by multiple myeloma. Methods: Free light chain removal was compared in the polymethylmethacrylate (PMMA) membrane Filtryzer BK-F, the polyphenylene HFR17 filter and the conventional polysulfone filter F7HPS. Twenty chronic hemodialysis patients were enrolled: mean age was 67.7 ± 17.0 years, M/F = 14/6, dialysis vintage (months) 25.5 ± 32.0. The patients were randomized into two groups of treatment lasting 6 weeks each. The dialysis sessions checked were the midweek sessions and the blood was drawn at times 0, 120' and 240'. Kappa (k) and lambda (λ) light chain levels, β2microglobulin (β2M), C reactive protein (CRP) and albumin were checked. Results: K light chain levels were 345.0 ± 100.0 mg/L, λ light chains were 121.4 ± 27.0 mg/L. The values of k light chains at times 120' and 240' were significantly lower with PMMA and HFR17 than those obtained with F7. The reduction ratio per session (RRs) for k light chains was 44.1 ± 4.3% with HFR17, 55.3 ± 3.4% with PMMA, 25.7 ± 8.3% with F7 (p = 0.018). The RRs for λ light chains was 30.3 ± 2.9% with HFR17, 37.8 ± 17.3% with PMMA, 14.0 ± 3.9% with F7 (p = 0.032). As to β2M, RRs was 42.4 ± 3.2% with HFR17 vs. 33.9 ± 2.8% with PMMA vs. 6.3 ± 1.9% with F7 (p = 0.022). The three filters tested showed no differences in CRP or albumin levels. Conclusion: In terms of light chain and β2M removal, the PMMA and on-line HFR filters are similar and both are significantly more effective than the F7 filter in chronic dialysis patients. Trial registration: The present trial was registered retrospectively (NCT02950389, 31/10/2016).