Ischemic steal syndrome in a hemodialysis patient: The roles of Doppler ultrasonography and dynamic Doppler studies in diagnosis and treatment selection.

Ischemic steal syndrome (ISS) is a complication that can occur after the construction of a vascular access for hemodialysis. It is characterized by ischemia of the hand caused by marked reduction or reversal of flow through the arterial segment distal to the arteriovenous fistula (AVF). The diagnosis of hand ischemia is based on physical examination, but imaging studies are very useful for detecting the true cause of ischemia and for selecting an appropriate therapeutic strategy. In this report, we describe an uncommon cause of ISS in a patient on hemodialysis. The ischemia was caused by the presence of undetected flow through an older AVF on the same arm as the AVF used for dialysis. The unsuspected "steal" was disclosed by color Doppler examination of the vascular bed of the patient's left arm. Dynamic Doppler studies then played a fundamental role in the decision to ligate the distal radio-cephalic AVF. The procedure led to the complete relief of ischemic symptoms.

[Diagnostic role of ambulatory blood pressure monitoring in non-dialysis CKD patients]. / Monitoraggio della pressione arteriosa per 24 ore: indicazioni e utilità nella IRC pre-dialitica.

In chronic kidney disease, blood pressure control is a major aim of therapy to slow down renal disease progression and reduce the cardiovascular risk. Ambulatory blood pressure monitoring is a valid tool to define the prognosis and indicated therapy for hypertension. It allows to detect blood pressure patterns such as the white-coat effect, resulting in a better definition of the cardiovascular risk profile. Description of the circadian pressure rhythm, moreover, may reveal the presence of physiological nocturnal loss (dipping status). Recently, it has been demonstrated that a non-dipping status is associated with a higher risk of end-stage renal disease and more rapid progression of kidney disease independent of blood pressure control. Furthermore, longitudinal studies have demonstrated that a non-dipping status is associated with increased cardiovascular morbidity and mortality in the general population and in hypertensive patients. We have less information on this issue in chronic kidney disease. In this high-risk subgroup of hypertensive patients, it remains ill-defined whether ambulatory blood pressure monitoring predicts cardiovascular outcomes better than in-office measurement.

[Heart failure in chronic kidney disease: from epidemiology to therapy]. / Lo scompenso cardiaco nel paziente con insufficienza renale cronica: dall'epidemiologia alla terapia.

Many patients affected by chronic kidney disease (CKD) die before reaching endstage renal disease because of cardiovascular disease (CVD). Recent guidelines and position statements have therefore defined CKD as a cardiovascular risk equivalent, and patients in all stages of CKD are considered in the highest risk group for development of CVD. Heart failure (HF) is the main cardiovascular complication that occurs in renal patients and its incidence increases proportionally with the reduction of glomerular filtration rate. In fact, pressure and volume overload, that are inherent to the abnormalities of homeostasis typical of CKD, lead to concentric/eccentric left ventricular hypertrophy (LVH). Initially, LVH is adaptative because energy is spared by maintaining stable wall stress. However, in the long term, LVH becomes maladaptative, inducing systolic and/or diastolic dysfunction that, in turn, lead to symptomatic left ventricular failure. Nowadays, it is well established that several classes of drugs, including reninangiotensin system antagonists, beta blockers and aldosterone antagonists, improve survival in patients with HF. In fact, all major guidelines on HF recommend such drugs as standard therapy. The problem for nephrologists is that the general approach and recommendations for the management of HF in the general population may not be completely safe in renal patients with HF. This review is conducted with the purpose to provide more information on the efficacy and safety of HF therapy in renal patients.