[Dialysis withdrawal and shared end-of-life management between nephrology and palliative care: our three-year experience].

Most dialysis patients with end-stage kidney disease (ESKD) lack access to palliative care services. According to the data of the Dialysis Outcomes and Practice Study (DOPPS), Italy when compared to other countries included in the study, had the lowest rates of dialysis discontinuation. Indeed, there is a growing interest in the implementation of international and national programs for the co-management between nephrology and palliative care in end-of-life decision-making for patients with ESKD. On behalf of this, since 2017, we started in the nephrology outpatient clinic and hemodialysis facilities of the Provincia Autonoma of Trento a shared program between Nephrology and Palliative Care Units to improve the end-of-life quality of care in ESKD patients in conservative and dialytic therapy. Methods:A retrospective analysis, from the 1st of January 2019 to 31st December 2021, of dialysis withdrawal in a cohort of patients undergoing hemodialysis and peritoneal dialysis. Results:Dialysis withdrawal and subsequent death, according to the integrated protocol with the Palliative Care resources, were 24 in 2019, 20 in 2020, and 28 in 2021. The mean age was 75 years in 2019, 78 years in 2020, and in 2021. Most of the patients were male. Dialysis discontinuation was higher in chronic dialysis patients (80% in 2019 and 2020, and 79% in 2021), and considering the annual rates of death of all the dialysis patients, those who died because of dialysis withdrawal were 38% in 2019, 31% in 2020 and 40% in 2021. Survival after dialysis withdrawal was in most of the cases less than 7 days; only few patients lived more than 30 days. Furthermore, the data, in the 3 years considered, showed a reduction of hospitalization and an increase of the rate of death at home. Conclusions:As described in the present study, strategies to expand palliative care by a shared protocol among nephrology and palliative care staff improved the quality of care in the end of life and reduced the hospitalization rates of admission of patients after dialysis withdrawal.

[SICI-GISE/SIN Consensus document: Contrast-induced acute kidney injury in interventional cardiology]. / Documento di consenso SICI-GISE/SIN: Danno renale acuto da mezzo di contrasto in cardiologia interventistica.

Contrast-induced acute kidney injury (CI-AKI) is a serious complication that can affect outcome and prognosis of patients undergoing percutaneous diagnostic and interventional procedures. The Italian Society of Interventional Cardiology (SICI-GISE) has promoted a consensus project on the subject of CI-AKI in order to disseminate and implement nephroprotection strategies in interventional cardiology. The initiative was conducted in partnership with the Italian Society of Nephrology (SIN).

Toll-like receptor 4 signalling mediates inflammation in skeletal muscle of patients with chronic kidney disease.

BACKGROUND: Inflammation in skeletal muscle is implicated in the pathogenesis of insulin resistance and cachexia but why uremia up-regulates pro-inflammatory cytokines is unknown. Toll-like receptors (TLRs) regulate locally the innate immune responses, but it is unknown whether in chronic kidney disease (CKD) TLR4 muscle signalling is altered. The aim of the study is to investigate whether in CKD muscle, TLRs had abnormal function and may be involved in transcription of pro-inflammatory cytokine. METHODS: TLR4, phospho-p65, phospho-ikBα, tumour necrosis factor (TNF)-α, phospho p38, Murf 1, and atrogin were studied in skeletal muscle from nondiabetic CKD stage 5 patients (n = 29) and controls (n = 14) by immunohistochemistry, western blot, and RT-PCR. Muscle cell cultures (C2C12) exposed to uremic serum were employed to study TLR4 expression (western blot and RT-PCR) and TLR-driven signalling. TLR4 signalling was abrogated by a small molecule chemical inhibitor or TLR4 siRNA. Phospho AKT and phospho p38 were evaluated by western blot. RESULTS: CKD subjects had elevated TLR4 gene and protein expression. Also expression of NFkB, p38 MAPK and the NFkB-regulated gene TNF-α was increased. At multivariate analysis, TLR4 protein content was predicted by eGFR and Subjective Global Assessment, suggesting that the progressive decline in renal function and wasting mediate TLR4 activation. In C2C12, uremic serum increased TLR4 as well as TNF-α and down-regulated pAkt. These effects were prevented by blockade of TLR4. CONCLUSIONS: CKD promotes muscle inflammation through an up-regulation of TLR4, which may activate downward inflammatory signals such as TNF-α and NFkB-regulated genes.

Study of the SRF-derived ashes melting behavior and the effects generated by the optimization of their composition on the furnaces energy efficiency in the incineration plants.

As regards the incineration process of the urban solid waste, the composition correct management allows not only the valorization of precise civil and industrial groups of waste as alternative fuels but also a considerable increase of the furnace work temperature leading to a remarkable improvement of the related energy efficiency. In this sense, the study of the melting behavior of ashes deriving from several kinds of fuels that have to be processed to heat treatment is really important. This approach, indeed, ensures to know in depth the features defining the melting behavior of these analyzed samples, and as a consequence, gives us the necessary data in order to identify the best mixture of components to be incinerated as a function of the specific working temperatures of the power plant. Firstly, this study aims to find a way to establish the softening and melting temperatures of the ashes because they are those parameters that strongly influence the use of fuels. For this reason, in this work, the fusibility of waste-derived ashes with different composition has been investigated by means of the heating microscope. This instrument is fundamental to prove the strict dependence of the ashes fusion temperature on the heating rate that the samples experienced during the thermal cycle. In addition, in this work, another technological feature of the instrument has been used allowing to set an instantaneous heating directly on the sample in order to accurately reproduce the industrial conditions which characterize the incineration plants. The comparison between the final results shows that, in effect, the achievement of the best performances of the furnace is due to the a priori study of the melting behavior of the single available components.

Vascular access in older patients: an Italian survey.

BACKGROUND: The number of older patients starting hemodialysis is continuously increasing. The type of vascular access plays an important role in dialysis treatment, but it can be difficult to create in older patients. METHODS: This study compared vascular access survival rates and patient survival rates in older (≥65 years) and younger (<65 years) patients starting hemodialysis in 2 Italian hospitals in 2006-2008. RESULTS: The study enrolled 336 patients: 208 ≥65 years and 128 <65 years of age. The vascular accesses used, in order of frequency, were 102 distal arteriovenous fistulas (dAVFs) (49%), 55 midarm AVFs (pAVFs) (26%), 9 arteriovenous grafts (AVGs) (4%) and 42 central venous catheters (CVCs) (20%) in the older patients, and 89 dAVFs (69%), 25 pAVFs (19%), 6 AVGs (5%) and 8 CVCs (6%) in the younger patients. Survival rates of fistula and catheter did not differ between the 2 groups. AVGs failed earlier (p = 0.02) in the older patients. On Cox analysis, age (hazard ratio [HR] = 1.073; p<0.001) and CVC (HR = 4.152; p<0.001) increased the risk of death. CONCLUSION: A fistula is the gold standard for hemodialysis vascular access in older patients if judged appropriately.

[A case of encapsulating peritoneal sclerosis after fifteen years of peritoneal dialysis with a favorable outcome]. / Un caso di peritonite sclerosante incapsulante con esito favorevole dopo 15 anni di dialisi peritoneale.

Encapsulating peritoneal sclerosis (EPS) represents a critical complication of peritoneal dialysis (PD). EPS is characterized by abdominal discomfort, often leading to fatal outcomes with limited pharmaceutical and surgical options. Herein is described a case of EPS with a favorable outcome in an African male treated with PD for 15 years. Repeated courses of prednisone and tamoxifen significantly attenuated the abdominal symptoms and the peritoneal membrane thickening. This case suggests a time dependent effect of medical treatment encouraging clinical efforts to maintain a mild immunosuppressant regimen and tamoxifen in the presence of EPS also on the long run. Future and ad hoc studies should test this hypothesis.

Atlas-based versus individual-based fiber tracking of the corpus callosum in patients with multiple sclerosis: reliability and clinical correlations.

BACKGROUND AND PURPOSE: In multiple sclerosis (MS), the presence of lesions and normal-appearing white matter damage may affect the reliability of diffusion tensor (DT) magnetic resonance imaging (MRI)-based tractography. We compared the performance of an individual-based method for corpus callosum (CC) fiber tracking in MS with those of two atlas-based methods. METHODS: Brain DT MRI scans were acquired from 35 patients with MS and 18 age-matched healthy volunteers (HV). DT-derived metrics from the CC-the mean diffusivity (MD) and fractional anisotropy (FA)-were calculated using an individual-based and two atlas-based methods with different types of subject registration (linear and nonlinear) to a CC atlas. Customized termination criteria were applied to stop the tracking algorithm when using the individual-based method. RESULTS: All the methods were able to distinguish between MS patients and HV. Using the individual-based method, stronger relationships were found between CC DT-derived metrics and the subjects' clinical condition. CONCLUSION: CC DT tractography using an individual-based method is more sensitive than the atlas-based ones to tract-specific alterations related to MS disability. An atlas-based method with nonlinear registration can be a valid alternative when an automated postprocessing is warranted, such as in the case of high volumes of data.

[When to start chronic dialysis: as late as possible]. / La linee grigia dell'inizio della dialisi: piu' tardi possibile.

Current recommendations for the initiation of dialysis are based on the level of kidney failure and on clinical evidence of uremia. Several nephrology societies advocate the early start of dialysis, i.e., when the glomerular filtration rate (GFR) is higher than or equal to 10 mL/min/1.73 m2, to minimize the clinical and social problems related to advanced uremia. It is not fully known whether the early start of dialysis is beneficial, harmful or neutral with respect to the outcome of dialysis treatment in end stage renal disease. Recent studies have reported no benefit in patient survival from initiating dialysis treatment at a higher GFR. The available data indicate that the mortality while on dialysis may be higher with an early start, and that there is no significant benefit in terms of quality of life. Whether this is explained by a greater comorbidity burden or detrimental effects of early initiation remains unclear. In clinical practice, there is considerable variation in the timing of initiation of maintenance dialysis for patients with end stage renal disease. We support initiating dialysis at a lower GFR (< -7.0 mL/min) provided that patients are given careful clinical management, and at an even lower rate in selected elderly patients given a supplemented very low protein diet. In this group of patients it is possible to initiate dialysis at a very low GFR (< -5 mL/min/1.73 m2) if there is careful management of the nutritional status, fluid and electrolyte balance, body weight, mineral metabolism, anemia, and blood pressure.

[Atheroembolic renal disease: a diagnostic challenge]. / La malattia renale ateroembolica: una sfida diagnostica.

Atheroembolic renal disease is a part of a multisystem disease and can be defined as renal failure secondary to the occlusion of renal arterioles and glomerular capillaries with cholesterol crystal emboli deriving from the aorta and other major arteries. The kidney is usually involved because of the proximity of the renal arteries to abdominal aorta (where the erosion of atheromatous plaque is most likely to occur), and the high renal blood flow. Cholesterol crystal embolism can also occur in other visceral organs, as well as in the upper and lower extremities. Embolization may occur spontaneously or after angiographic and surgical procedures, and anticoagulation. Atheroembolic renal disease is an important yet underdiagnosed component of the spectrum of kidney diseases associated with atherosclerosis and remains an unexplored field of nephrology research.

The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors.

BACKGROUND: Atheroembolic renal disease (AERD) is caused by showers of cholesterol crystals released by eroded atherosclerotic plaques. Embolization may occur spontaneously or after angiographic/surgical procedures. We sought to determine clinical features and prognostic factors of AERD. METHODS AND RESULTS: Incident cases of AERD were enrolled at multiple sites and followed up from diagnosis until dialysis and death. Diagnosis was based on clinical suspicion, confirmed by histology or ophthalmoscopy for all spontaneous forms and for most iatrogenic cases. Cox regression was used to model time to dialysis and death as a function of baseline characteristics, AERD presentation (acute/subacute versus chronic renal function decline), and extrarenal manifestations. Three hundred fifty-four subjects were followed up for an average of 2 years. They tended to be male (83%) and elderly (60% >70 years) and to have cardiovascular diseases (90%) and abnormal renal function at baseline (83%). AERD occurred spontaneously in 23.5% of the cases. During the study, 116 patients required dialysis, and 102 died. Baseline comorbidities, ie, reduced renal function, presence of diabetes, history of heart failure, acute/subacute presentation, and gastrointestinal tract involvement, were significant predictors of event occurrence. The risk of dialysis and death was 50% lower among those receiving statins. CONCLUSIONS: Clinical features of AERD are identifiable. These make diagnosis possible in most cases. Prognosis is influenced by disease type and severity.

Cholesterol crystal embolism (atheroembolism).

Cholesterol crystal embolism, known as atheroembolic disease, is caused by showers of cholesterol crystals from an atherosclerotic plaque that occludes small arteries. Embolization can occur spontaneously or as an iatrogenic complication from an invasive vascular procedure (angiography or vascular surgery) and after anticoagulant therapy. The atheroembolism can give rise to different degrees of renal impairment. Some patients show a moderate loss of renal function, others severe renal failure requiring dialysis. Renal outcome can be variable: some patients deteriorate or remain on dialysis, some improve and some remain with chronic renal impairment. Clinically, three types of atheroembolic renal disease have been described: acute, subacute or chronic. More frequently a progressive loss of renal function occurs over weeks. Atheroembolization can involve the skin, gastrointestinal system and central nervous system. The diagnosis is difficult and controversial for the protean extrarenal manifestations. In the past, the diagnosis was often made post-mortem. In the last 10 yrs, awareness of atheroembolic renal disease has improved. The correct diagnosis requires the clinician to be alert. The typical patient is a white male aged >60 yrs with a history of hypertension, smoking and arterial disease. The presence of a classic triad (precipitating event, renal failure and peripheral cholesterol crystal embolization) suggests the diagnosis. This can be confirmed by a biopsy of the target organs. A specific treatment is lacking; however, it is an important diagnosis to make because an aggressive therapeutic approach can be associated with a more favorable clinical outcome.