Impact of Serum Phosphorus on Hemoglobin: A Literature Review.

Phosphorus is a macroelement found in the body, mostly in the bones as crystals of hydroxyapatite. Higher levels are found in patients affected by chronic kidney disease (CKD). Since the early stage of CKD phosphorous excretion is impaired, but the increase of PTH and FGF23 maintains its level in the normal range. In the last decades, the role of FGF23 in erythropoiesis was studied, and now it is well known for its role in anemia genesis in patients affected by conservative CKD. Both Hyperphosphatemia and anemia are two manifestations of CKD, but many studies showed a direct association between serum phosphorous and anemia. Phosphorus can be considered as the common point of more pathogenetic ways, independent of renal function: the overproduction of FGF23, the worsening of vascular disease, and the toxic impairment of erythropoiesis, including the induction of hemolysis.

[Executive Dysfunction in Patients Undergoing Chronic Haemodialysis Treatment: A Possible Symptom of Vascular Dementia].

Introduction. Patients undergoing chronic haemodialysis (HD) treatment have an 8-10 times higher risk of experiencing stroke events and developing cognitive impairment. The high vascular stress they are subjected to may be the basis for the development of vascular dementia (VaD). Objective. The aim of the study is to investigate the executive functions, typically impaired in VaD, of patients undergoing chronic haemodialysis treatment. Method. HD patients were recruited from the U.O.C. of Nephrology and Dialysis (ASP Ragusa). Risk factors for VaD were collected and then the Frontal Assessment Battery (FAB) was administered. Results. 103 HD patients were included (males = 63%, age 66 ± 14 years). Risk factors for VaD included a high percentage of patients with anaemia (93%), hypertension (64%) and coronary artery disease (68%). The cognitive data obtained via FAB show a percentage of 55% deficit scores. All risk factors found a significant association with cognitive scores. Anemia, hypertension, intradialytic hypotension, coronary artery disease, and homocysteine are negative predictors of executive function integrity. Conclusions. More than half of the patients had deficit scores on the FAB. Reduced cognitive flexibility, high sensitivity to interference, poor inhibitory control and impaired motor programming with the dominant hand were evident. In conclusion, a marked impairment of the executive functions, generally located in the frontal lobes of the brain, was detected in the HD patient, which could be a symptom of a dementia of a vascular nature.

[Sleep quality of patients in End Stage Renal Disease before and after starting chronic hemodialysis treatment: a longitudinal study].

Introduction: Sleep disorders are very common in patients with chronic kidney disease, with a prevalence of poor sleep quality of around 40%. Objectives: The purpose of the study is to compare the sleep quality of ESRD patients before hemodialysis (Pre-HD), three months (Post-HD 1) and six months after the start of treatment (Post-HD 2) through the use of the Pittsburgh Sleep Quality Index (PSQI). Methods: Patients in ESRD were recruited from the U.O.C. of Nephrology and Dialysis of the Maggiore Hospital in Modica and biographical and anamnestic data were collected. The PSQI was administered in-person at the Pre-HD stage and by telephone re-test at the three- and six-month follow-up. Results: A total of 71 patients (males=62%, age 68 ± 16) were included. At Pre-HD assessment 93% reported poor sleep quality, the percentage increased to 98% during Post-HD 1 and it partially improved during Post-HD 2 with a prevalence of 95%. Analysis of variance (ANOVA) by repeated measures showed a difference in sleep quality between the three time points. Conclusions: Sleep quality undergoes important changes during the transition from conservative to hemodialysis patient, highlighting a critical period related to the first three months of treatment. More attention to this phase may improve the patient's quality of life and reduce the associated risk of mortality.

[Contrast Media Toxicity and Its Prevention].

Intravenous iodinated contrast media are commonly used in clinical practice, ranging from medical imaging to interventional radiology (IR) procedures and endovascular interventions. Compared with patients with normal renal function, nephropathic patients have an increased risk of acute kidney injury (AKI). Nevertheless, this condition cannot represent a limit to diagnostics or endovascular interventions. Despite the literature of the last five years, conflicting management and approaches for nephropathic patients persist, including the use of contrast agents and treatments replacing renal functions, which are often mistakenly considered as part of preventive strategies. Though the issue has been widely discussed, specialists often cope with uncertainty in handling properly the administration of contrast media and renal counselling requests. Furthermore, there is a general difficulty in distinguishing the Post-Contrast Acute Kidney Injury (PC-AKI) from the Contrast-Associated Acute Kidney Injury (CI-AKI). The present review aims to provide an update on the issue and examine strategies to reduce the acute kidney injury risk after the administration of contrast media. These strategies include the early identification of high-risk individuals, the choice of the contrast media and the proper dosage, the suspension of nephrotoxic drugs, the follow-up of the high-risk individuals, and the early identification of AKI.

[The management of nephropathic patients during the Covid-19 pandemic: the experience of Ragusa].

The public emergency caused by Covid-19 has forced health services to reorganize in order to separate positive patients from negative ones. In nephrology, this reorganization involves several levels of assistance concerning hospitalizations, ambulatory care and haemodialysis. Within the Complex Unit of Nephrology in Ragusa, the distribution of nephro-dialytic resources has involved four different hospitals, hence ensuring haemodialysis services for asymptomatic and pauci-symptomatic Covid-19 patients as well as for patients in Covid-Unit, Sub-Intensive Therapy and Intensive Care Unit. In this complex context, we had to create a common protocol involving all the professionals who provide assistance in our Unit, across the different structures. We also report some encouraging data that seem to indicate the effectiveness of the protocols put in place.

[Osteoporosis and chronic kidney disease: review and new therapeutic strategies].

Osteoporosis affects a segment of the population in which Chronic Kidney Disease is also greatly represented. Nephropathic patients may present peculiar biochemical abnormalities related to Chronic Kidney Disease, defining the Mineral and Bone Disorder. This kind of anomalies, in the worst scenarios, configure the typical histomorphology patterns of Renal Osteodystrophy. Scientific Societies of Endocrinology have established therapy guidelines for patients with osteoporosis only based on the glomerular filtration rate and recommend avoiding the use of some drugs for the more advanced classes of nephropathy. However, there is no clear therapeutic approach for patients with advanced nephropathy and bone abnormalities. In this paper we propose a systematic review of the literature and present our proposal for managing patients with advanced nephropathy, based on eGFR and on presence of Mineral and Bone Disorder.

[Renal diseases related to MYH9 disorders].

Mutations in MYH9 gene encoding the nonmuscle myosin heavy chain IIA (NMMHC-IIA) are related to a number of rare autosomal-dominant disorders which has been known as May-Hegglin disease, Sebastian syndrome, Fechtner syndrome and Epstein syndrome. Their common clinical features are congenital macrothrombocytopaenia and polymorphonuclear inclusion bodies, in addition to a variable risk of developing proteinuria, chronic kidney disease progressing toward end stage, sensorineural deafness and presenile cataracts. The term MYH9 related disease (MYH9-RD) describes the variable expression of a single illness encompassing all previously mentioned hereditary disorders. Renal involvement in MYH9- RD has been observed in 30% of patients. Mutant MYH9 protein, expressed in podocytes, mesangial and tubular cells, plays a main role in foot process effacement and in development of nephropathy. Interestingly, the MYH9 gene is currently under investigation also for his possible contribution to many other non-hereditary glomerulopathies such as focal global glomerulosclerosis (hypertensive nephrosclerosis), idiopathic focal segmental glomerulosclerosis, C1q nephropathy and HIV-associated nephropathy. In this review we are aimed to describe renal diseases related to MYH9 disorders, from the hereditary disease to the acquired disorders, in which MYH9-gene acts as a "renal failure susceptibility gene".

CVVHD treatment with CARPEDIEM: small solute clearance at different blood and dialysate flows with three different surface area filter configurations.

BACKGROUND: The CARdiorenal PEDIatric EMergency (CARPEDIEM) machine was originally designed to perform only continuous venovenous hemofiltration (CVVH) in neonatal and pediatric patients. In some cases, adequate convective clearance may not be reached because of a limited blood flow. In such conditions, the application of diffusive clearance [continuous venovenous hemodialysis (CVVHD)] would help optimize blood purification. In this study, the CARPEDIEM™ machine was modified to enable the circulation of dialysis through the filter allowing testing of the performance of CARPEDIEM™ machine in CVVHD. METHODS: Three different polyethersulfone hemodialyzers (surface area = 0.1 m(2), 0.2 m(2), and 0.35 m(2), respectively) were tested in vitro with a scheduled combination of plasma flow rates (Qp = 10-20-30 ml/min) and dialysis fluid flow rate (Qd = 5-10-15 ml/min). Three sessions were performed in co-current and one in counter-current configuration (as control) for each filter size. Clearance was measured from the blood and dialysate sides and results with mass balance error greater than 5 % were discarded. RESULTS: Urea and creatinine clearances for each plasma/dialysate combination are reported: clearance increase progressively for every filter proportionally to plasma flow rates. Similarly, clearances increase progressively with dialysate flow rates at a given plasma flow. The clearance curve tends to present a steep increase for small increases in plasma flow in the range below 10 ml/min, while the curve tends to plateau for values averaging 30 ml/min. As expected, the plateau is reached earlier with the smaller filter showing the effect of membrane surface-area limitation. At every plasma flow, the effect of dialysate flow increase is evident and well defined, showing that saturation of effluent was not achieved completely in any of the experimental conditions explored. No differences (p > 0.05 for all values) were obtained in experiments using whole blood instead of plasma or using co-current versus counter-current dialysate flow configuration. CONCLUSIONS: Although plasma flow and filter surface give an important contribution to the level of clearance urea and creatinine, it appears evident that dialysate flow plays an essential role in the blood purification process, justifying the use of CVVHD versus CVVH in case of high dialysis dose requirement and/or limited blood flow rate.

[Usefulness of sCD14-ST in the diagnosis of sepsis in patient with renal failure]. / Utilità dell'sCD14-ST per la diagnosi di sepsi nel paziente con insufficienza renale.

Since many years, researchers have focused their studies to find out early sepsis biomarkers for the purpose of gaining time in the application of early goal-directed therapy protocol. Procalcitonin (PCT) is a reliable biomarker for sepsis, although it has a low specificity and prognostic value. Other recently proposed sepsis biomarkers such as interleukins, C-reactive protein (CRP), myeloid cells expressing triggering receptor-1 (TREM-1) and soluble urokinase-type plasminogen activator receptor (suPAR) still have a controversial and uncertain clinical value. In 2004 a new biomarker, soluble CD14 SubType (sCD14-ST, Presepsin), with a good performance in the diagnosis and prognostic evaluation of sepsis has been proposed. First studies highlighted that Presepsin is highly sensitive and specific at the same time. However, further studies on the clinical value of Presepsin are needed, particularly in order to explain the relationship between Presepsin and kidney failure. Indeed, Presepsin is a 13 KDa molecule theoretically totally filtered by glomerulus and reabsorbed and metabolized by proximal convoluted tubules. Therefore, the Presepsin plasmatic level could be highly influenced by an acute kidney injury in the course of sepsis or by a pre-existing chronic kidney disease. In this article we reviewed the latest evidences about the diagnostic and prognostic performances of Presepsin as a sepsis biomarker. We evaluated the usefulness of Presepsin in the context of acute and chronic kidney dysfunction. The great number of articles have been collected and the thorough revision of data from the nephrologists perspective let us consider this work exhaustive and scientifically reliable, although concise: a good starting point for the physician who wants to make use of Presepsin.

[Muscle-wasting in end stage renal disease in dialysis treatment: a review]. / La sarcopenia nell'uremico terminale in trattamento dialitico.

Progressive and generalized loss of muscle mass (muscle wasting) is a frequent complication in dialysis patients. Common uremic signs and symptoms such as insulin-resistance, increase in glucocorticoid activity, metabolic acidosis, malnutrition, inflammation and dialysis per se contribute to muscle wasting by modulating proteolytic intracellular mechanisms (ubiquitin-proteasome system, activation of caspase-3 and IGF-1/PI3K/Akt pathway). Since muscle wasting is associated with an increase in mortality, bone fractures and worsening in life quality, a prompt and personalised diagnostic and therapeutic approach seems to be essential in dialysis patients. At present, nuclear magnetic resonance (NMR), computed tomography (CT), dual-energy x-ray absorptiometry (DXA), impedance analysis, bioelectric impedance analysis (BIA) and anthropometric measurements are the main tools used to assess skeletal muscle mass. Aerobic and anaerobic training programmes and treatment of uremic complications reduce muscle wasting and increase muscle strength in uremic patients. The present review analyses the most recent data about the physiopathology, diagnosis, therapy and future perspectives of treatment of muscle wasting in dialysis patients.

[IgG4-related kidney disease: what the nephrologist needs to know]. / Malattia renale IgG-4 correlata: cosa il nefrologo deve sapere.

IgG4 related disease is a systemic fibro-inflammatory disorder characterized by multiple organ and multiple tissue lesions. The real pathogenesis is currentlyactually unknown. For these reasons many authors compare IgG4 related disease to sarcoidosis. Lesions are often localized in the pancreas, salivary and lacrimal glands, biliary ducts, retroperitoneum and in many other organs. The diagnosisis difficult because of mild symptoms and the possibility of mimicking other severe diseases. Therefore, histopathology together with clinical and radiological typical findings are mandatory tools for diagnosis. Steroidtherapy usually enables disappearance of tumor like lesions and complete recovery. Kidney has an extensive organ involvement in the contextof IgG4-related disease. Historically, tubule - interstitial nephritis(TIN) is considered the main renal feature of renal lesions, however recent studies extend the spectrum of renal lesions also to glomerular tuft. These findings allow to introduce in the nosography the term of IgG4related kidney disease (IgG4 RKD). This review focuses on renal involvement in IgG4related disease, in order to help nephrologists to improve their clinical, diagnostic and therapeutic approach to this emerging pleiotropic clinical pattern.