[Social media for continuing education in nephrology. Myth or reality?]

About 60% of the world population has access to the Internet in 2021, making it the main tool in fostering communication between people. Lately, digital information and communication have especially taken place on platforms known as Social Media (SoMe) or Social Networks. In the last decade the usefulness of these tools in carrying information aimed at updating professionals in Medicine and Nephrology has become evident. There are several examples of SoMe utilization in Nephrology, as demonstrated by the existing accounts or Pages operated by the main international nephrological Scientific Societies, or the most renowned specialized medical journals. Twitter, Facebook and YouTube are the most versatile SoMe for these objectives; however, other platforms such as Tik Tok, Linkedin, Instagram, and WhatsApp may serve the same purpose. This digital revolution in disseminating information has proved very useful during the recent COVID-19 pandemic, even though some inappropriate uses have emerged, such as the diffusion of fake news, which has favored the emergence of "adverse effects" or a surge of antiscientific positions. In this review, we examine how physicians and nephrologists can take advantage of digital information for their continuing education. We quote the main resources in the international scenario and illustrate some specific national examples, such as the Journal Club of the Nephrology post-graduate program of the University of Milan and the Facebook group "Medical and Nephrology Community".

[Nephrology: where we stand and where we should go].

In the last year, the Italian National Health Service as a whole and the Nephrology community have been severely challenged by the pandemic. It has been a dramatic stress test for the entire healthcare system, not only in Italy but worldwide. The general organization of our Nephrology units and our models of care were put under extreme pressure, and we had to quickly adopt unprecedented clinical practice recommendations and organizational models to overcome the impasse caused by the pandemic. The time has come to evaluate these new experiences, ask how we could have been better prepared and look for change. In this editorial, we outline a few proposals and suggestions for the future, weighing the information gathered in the 2018 Nephrology Census against the new organizational requirements imposed by the COVID-19 pandemic.

Risk factors and action thresholds for the novel coronavirus pandemic. Insights from the Italian Society of Nephrology COVID-19 Survey.

BACKGROUND AND AIM: Over 80% (365/454) of the nation's centers participated in the Italian Society of Nephrology COVID-19 Survey. Out of 60,441 surveyed patients, 1368 were infected as of April 23rd, 2020. However, center-specific proportions showed substantial heterogeneity. We therefore undertook new analyses to identify explanatory factors, contextual effects, and decision rules for infection containment. METHODS: We investigated fixed factors and contextual effects by multilevel modeling. Classification and Regression Tree (CART) analysis was used to develop decision rules. RESULTS: Increased positivity among hemodialysis patients was predicted by center location [incidence rate ratio (IRR) 1.34, 95% confidence interval (CI) 1.20-1.51], positive healthcare workers (IRR 1.09, 95% CI 1.02-1.17), test-all policy (IRR 5.94, 95% CI 3.36-10.45), and infected proportion in the general population (IRR 1.002, 95% CI 1.001-1.003) (all p < 0.01). Conversely, lockdown duration exerted a protective effect (IRR 0.95, 95% CI 0.94-0.98) (p < 0.01). The province-contextual effects accounted for 10% of the total variability. Predictive factors for peritoneal dialysis and transplant cases were center location and infected proportion in the general population. Using recursive partitioning, we identified decision thresholds at general population incidence ≥ 229 per 100,000 and at ≥ 3 positive healthcare workers. CONCLUSIONS: Beyond fixed risk factors, shared with the general population, the increased and heterogeneous proportion of positive patients is related to the center's testing policy, the number of positive patients and healthcare workers, and to contextual effects at the province level. Nephrology centers may adopt simple decision rules to strengthen containment measures timely.

Italian Society of Nephrology's 2018 census of renal and dialysis units: the nephrologist's workload / Censimento della Società Italiana di Nefrologia delle strutture nefrologiche e della loro attività in Italia nel 2018: il lavoro del nefrologo

Background: Given the public health challenge represented by chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyze structural and human resources, organizational aspects, activities and workload, referring to the year 2018. Methods: An on-line questionnaire including 60 questions, exploring structural and human resources, organizational aspects, activities and epidemiological data referred to 2018, was sent to the heads of all identified Italian renal or dialysis unit. Results: Renal and dialysis activity was performed by over 2,718 physicians (41 pmp). The management of the acute renal failure was one of the most relevant activities in the public renal units (3,000 pmp patients in ICU and 183.000 dialysis sessions). Italian Nephrologists performed about 6000 AV fistulas out of a total of 9300. In the survey there are a lot of data regarding organization, workforce and workload of the renal unit in Italy. Conclusions: Data from this census may be used for benchmarking and comparison between centers, regions and groups of regions. These data offer a snapshot of the clinical management of renal disease in Italy.

Italian Society of Nephrology's 2018 census of renal and dialysis units: their structure and organization / Censimento a cura della Società Italiana di Nefrologia delle strutture nefrologiche e delle loro attività in Italia nel 2018: l'organizzazione

Background: Given the public health challenge represented by chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyze structural and human resources, organizational aspects, activities and workload, referring to the year 2018. Methods: An on-line questionnaire including 60 questions, exploring structural and human resources, organizational aspects, activities and epidemiological data referred to 2018, was sent to the heads of all identified Italian renal or dialysis unit. Results: 567 renal units were identified, 3.3 public and full renal unit pmp. The nephrology beds are about 37.6 pmp. The nurses were 8,130 in HD wards, 1,827 in the nephrology wards, only 432 for outpatient clinics. Conclusions: Data from this census may be used for benchmarking and comparison between centers, regions and groups of regions. These data offer a snapshot of the clinical management of renal disease in Italy.

Exposure to novel coronavirus in patients on renal replacement therapy during the exponential phase of COVID-19 pandemic: survey of the Italian Society of Nephrology.

BACKGROUND: Between February and April 2020, Italy experienced an overwhelming growth of the COVID-19 pandemic. Little is known, at the country level, where and how patients on renal replacement therapy (RRT) have been mostly affected. METHODS: Survey of the network of Nephrology centers using a simplified 17 items electronic questionnaire designed by Italian Society of Nephrology COVID-19 Research Group. We used spatial epidemiology and geographical information systems to map SARS-CoV-2 spread among RRT patients in Italy. RESULTS: On April 9th 2020, all nephrology centers (n = 454) listed in the DialMap database were invited to complete the electronic questionnaire. Within 11 days on average, 365 centers responded (80.4% response rate; 2.3% margin of error) totaling 60,441 RRT patients. The surveyed RRT population included 30,821 hemodialysis (HD), 4139 peritoneal dialysis (PD), and 25,481 transplanted (Tx) patients respectively. The proportion of SARS-CoV-2 positive RRT patients in Italy was 2.26% (95% CI 2.14-2.39) with significant differences according to treatment modality (p < 0.001). The proportion of patients positive for SARS-CoV-2 was significantly higher in HD (3.55% [95% CI 3.34-3.76]) than PD (1.38% [95% CI 1.04-1.78] and Tx (0.86% [95% CI 0.75-0.98]) (p < 0.001), with substantial heterogeneity across regions and along the latitude gradient (p < 0.001). In RRT patients the highest rate was in the north-west (4.39% [95% CI 4.11-4.68], followed by the north-east (IR 2.06% [1.79-2.36]), the center (0.91% [0.75-1.09]), the main islands (0.67% [0.47-0.93]), and the south (0.59% [0.45-0.75]. During the COVID-19 pandemic, among SARS-Cov-2 positive RRT patients the fatality rate was 32.8%, as compared to 13.3% observed in the Italian population as of April 23rd. CONCLUSIONS: A substantial proportion of the 60,441 surveyed RRT patients in Italy were SARS-Cov-2 positive and subsequently died during the exponential phase of COVID-19 pandemic. Infection risk and rates seems to differ substantially across regions, along geographical latitude, and by treatment modality.

[Methodology for determining workforce in health nephrologic unit in ITALY. Update of lows].

Nephrology continues to be in transition. While rates of kidney diseases and injury continue to rise, changes in the general health care system and the delivery of kidney care make it unclear how increases in need will be translated into demand for nephrologists. The changes in the delivery system also raise questions as to the future roles and career paths for nephrologists. There a major interrelated workforce issues to be watched closely : how many nephrologists are needed ? The supply of nephrologists does not reflect the distribution of patients with kidney diseases or the activity and job description related to end stage renal disease (ESRD) patients. Looking forward, more needs to be done to systematically measure need and access, and to identify clinical areas and activity of high need for nephrologists. This review examines the laws that govern the measure of work and the needs of personnel of the Italian state and in particular in health care. Therefore, once the method is accepted and established, it will be possible communicate those findings to policy makers and fellows and to involve the politicians.

[Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program].

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

[Inapparent charges for the assistance to nephropathic patient on dialysis].

The increasing technological effectiveness has undoubtedly produced an improvement in clinical parameters of dialysis patients, but this satisfactory therapeutic result did not follow an adequate improvement in mortality or in the perception of quality of life as per patients. Furthermore, dialysis treatment is often associated with "inapparent charges" that reduce the perception of well-being, independently of clinical changes. Thirty years ago, we carried out a national survey on inapparent charges, which represent frustrating aspects that negatively affect patients' perception of their quality of life. Thirty years later, it seemed important for us to repeat the survey to understand if Italian legislative remodeling have introduced changes in procedures and social aspects of dialysis, as preservation of quality of life is an important aspect of the replacement treatment.

Nutritional treatment of advanced CKD: twenty consensus statements.

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

[Nephrologic workforce. Who we are? Where do we go? A project by SIN]. / La Workforce nefrologica in Italia. Chi siamo e dove andiamo: un progetto SIN.

The SIN Workforce Working Group has carried out an initial demographic study project that highlights the situation of nephrological workforce in European and non-European countries, noting in particular the apparent discrepancies between the number of nephrologists in other health systems and in the Italian one. Italy seems to have the highest number of nephrologists per capita: in fact, the number of nephrologists has decreased in recent years due to the number of retirements far higher than the entry of new specialists. The project arises from the need to define the actual number of nephrologists in Italy in relation to the population and the epidemiology of chronic renal disease, taking into account the trends of ageing and feminization of our specialty. The tools used to collect data on the demographics of Italian nephrologists are a database for demographic data collection by presidents of SIN regional sections and a questionnaire for a survey to describe demography, workload, the adhesion to the discipline and the recruitment and retirement programs of the Italian nephrological community.

[Italian health centers and Web Marketing strategy: necessary improvements, even in nephrology]. / Aziende sanitarie italiane e Web Marketing strategy: miglioramenti indispensabili, anche in nefrologia.

The complete digitalization of the health system is an objective that Italy, from 2014, is pursuing with great difficulty, spurred by the many European initiatives dedicated to it. Despite the social and cultural background seems to be clearly ready for an application of the renewal strategies, e-Health and m-Health are struggling to get off the ground throughout the territory. The main difficulties are find at local level and don't spare any medical discipline, nephrology included. The characteristics of the official websites belonging to the local health centers demonstrate it. Today, these institutions are still sparsely present on Social Media or in the Italian Smart Mobile Technology landscape. The article illustrates the main features of the phenomenon and calls for reflection on the necessity to accelerate the digital innovation of the communication with patients. This is a possible strategy for reducing chronicity through prevention, and, potentially, for decreasing health costs.

Controversial issues in CKD clinical practice: position statement of the CKD-treatment working group of the Italian Society of Nephrology.

This position paper of the study group "Conservative treatment of Chronic Kidney Disease-CKD" of the Italian Society of Nephrology addresses major practical, unresolved, issues related to the conservative treatment of chronic renal disease. Specifically, controversial topics from everyday clinical nephrology practice which cannot find a clear, definitive answer in the current literature or in nephrology guidelines are discussed. The paper reports the point of view of the study group. Concise and practical advice is given on several common issues: renal biopsy in diabetes; dual blockade of the renin-angiotensin-aldosterone system (RAAS); management of iron deficiency; low protein diet; dietary salt intake; bicarbonate supplementation; treatment of obesity; the choice of conservative therapy vs. dialysis. For each topic synthetic statements, guideline-style, are reported.

[Census of the renal and dialysis units by Italian Society of Nephrology: nephrologist's workload for renal patient assistance in Italy (2014-2015)]. / Censimento a cura della Società Italiana di Nefrologia delle strutture nefrologiche e della loro attività in Italia nel 2014-2015: il lavoro del nefrologo.

BACKGROUND: Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted acensusof the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to theyear 2014. METHODS: An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit. RESULTS: Renal and dialysis activity was performed by over 2718 physicians (45 pmp). The management of the acute renal failure was one of the most frequent activities in the public renal units (12,206 patients in ICU and 140.00 dialysis sessions). There were performed about 9000 AV fistulas and 1700 central vascular catheters insertions. In the census, there are a lot of data regarding organization, workforce and workload of the renal unit in Italy. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

[Census of the renal and dialysis units by Italian Society of Nephrology: structure and organization for renal patient assistance in Italy (2014-2015)]. / Censimento a cura della Società Italiana di Nefrologia delle strutture nefrologiche e delle loro attività in Italia nel 2014-2015: l'organizzazione.

BACKGROUND: Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to the year 2014. METHODS: An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit. RESULTS: 615 renal units were identified. From these 615 units, 332 were public renal centres (of which 318 centres answered to the census) and 283 were private dialysis centres (of which 113 centres answered to the census). The results show 6 public renal units pmp. Renal biopsies were 4624 (81 pmp). The nephrology beds are about 41 pmp. There are 7.304 nurses working in HD wards, 1.692 in the nephrology wards and only 613 for outpatients clinics. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

[Acute Kidney Injury: the nephrology plus value and competence and a good organization can ameliorate the prognosis]. / Insufficienza Renale Acuta: il plus valore e la competenza del nefrologo, unitamente ad una buona organizzazione, possono migliorare la prognosi.

Epidemiology of Acute Kidney Injury (AKI) has changed radically in the past 15 years: we have observed an exponential increase of cases with high mortality and residual disability, particularly in those patients who need dialysis treatment. Those who survive AKI have an increased risk of requiring dialysis after hospital discharge over the short term as well as long term. They have an increased risk of deteriorating residual kidney function and cardiovascular events as well as a shorter life expectancy. Given the severe prognosis, difficulties of treatment, high level of resources needed, increased workload and consequently costs, several aspects of AKI have not been sufficiently investigated. Any national register of AKI has not been developed and its absence has an impact on provisional strategies. Specific training should be planned beginning with University, which should include practical training in Intensive Care Units. A definition of the organizational characteristics and requirements for the care of AKI is needed. Treatment of AKI is not based exclusively on dialysis efficiency or technology, but also on professional skills, volume of activity, clinical experience, model of healthcare organizations, continuity of processes and medical activities to guarantee such as a closed-staff system. Progress in knowledge and technology has only partially modified the outcome and prognosis of AKI patients; consequently, new strategies based on increased awareness, on the implementation of professional skills, and on revision, definition and updating of resources for the organization of AKI management are needed and expected over the short term.

Low-protein diets for chronic kidney disease patients: the Italian experience.

BACKGROUND: Nutritional treatment has always represented a major feature of CKD management. Over the decades, the use of nutritional treatment in CKD patients has been marked by several goals. The first of these include the attainment of metabolic and fluid control together with the prevention and correction of signs, symptoms and complications of advanced CKD. The aim of this first stage is the prevention of malnutrition and a delay in the commencement of dialysis. Subsequently, nutritional manipulations have also been applied in association with other therapeutic interventions in an attempt to control several cardiovascular risk factors associated with CKD and to improve the patient's overall outcome. Over time and in reference to multiple aims, the modalities of nutritional treatment have been focused not only on protein intake but also on other nutrients. DISCUSSION: This paper describes the pathophysiological basis and rationale of nutritional treatment in CKD and also provides a report on extensive experience in the field of renal diets in Italy, with special attention given to approaches in clinical practice and management. Italian nephrologists have a longstanding tradition in implementing low protein diets in the treatment of CKD patients, with the principle objective of alleviating uremic symptoms, improving nutritional status and also a possibility of slowing down the progression of CKD or delaying the start of dialysis. A renewed interest in this field is based on the aim of implementing a wider nutritional therapy other than only reducing the protein intake, paying careful attention to factors such as energy intake, the quality of proteins and phosphate and sodium intakes, making today's low-protein diet program much more ambitious than previous. The motivation was the reduction in progression of renal insufficiency through reduction of proteinuria, a better control of blood pressure values and also through correction of metabolic acidosis. One major goal of the flexible and innovative Italian approach to the low-protein diet in CKD patients is the improvement of patient adherence, a crucial factor in the successful implementation of a low-protein diet program.

[Italian Registry Dialysis and Transplant 2011-2013]. / Report del Registro Italiano di Dialisi e trapianto relativo agli anni 2011-2013.

UNLABELLED: The Italian Registry of Dialysis and Transplantation (RIDT) has recently resumed the collection of data of patients on RRT in Italy. Data were requested to Regional Registries for the years 2011-2013 and they contributed according to their possibilities. Eighteen Regions or autonomous Provinces provided data with various degrees of completeness and this made possible to bridge the gap between the current and the previous census (referring to 2010). RESULTS: Incidencedata were associated to a sample with a coverage of 77% of the national population (46/60 million inhabitants). Patients who started dialysis in these three years were, respectively, 168, 166 and 160 patients pmp. If we project this data to the national population is reasonable to think that 9500-10000 patients per year start the dialytic treatment. PREVALENCE: The prevalence of patients on dialysis in Italy range, in the 10 years of RIDT, between 750 and 825 patients pmp. Based on this we can reasonably estimate that in Italy there are 45-49000 dialysis patients. Incidence and prevalence vary widely in different regions. Mortalityon dialysis in Italy during the period 2011-2013 was on average 16.2 per 100 patient-years (95% CI: 16.1-16.7) with regional variation smaller than that observed in incidence and prevalence. CONCLUSIONS: In this paper, data analysis are presented in a direct and non comparative manner. However, it provides information on the status of the RRT in Italy and the temporal consistency of the data is a proof of their validity. Registry data were published in the official site of Italian Registry that can be reached through the website of SIN (www.sin-italy.org).

[Does clinical methodology yet exist?] / Metodologia in clinica: esiste ancora?

Up to 1968, clinical methodology was considered a central step in construction of Medical procedure. Later, after specialization or high specialization introduction, it totally disappeared. The results is the absence of any epistemological knowledge in the construction of diagnosis, based on two main theory: inductivism and hypothetico-deductivism. Both start from the point that diagnostic theory can be developed in close touch with experiment and observation. The inductive theory builds up the diagnosis on the multiple observations, while the deductive theory formulates the diagnosis from the bright idea which inspires the doctor who then has to check his theory by observation. The difference between two approaches to diagnosis is based on the tabula rasa of inductive physician and tabula plena of deductive physician. Without a methodology knowledge, the new doctors are lacking of proper correct approach to right diagnosis and therapy and rarely use academic tools to deepen it in clinical work. We consider many epistemology clinical aspects related to science and medical practice. In addition, we point out the attention to some cases on the basis of new inductive and deductive theories, in order to have respect for patients and doctors dignity.