Effect of renal artery stenting on left ventricular mass: a randomized clinical trial.

BACKGROUND: Whether renal revascularization reduces left ventricular hypertrophy in patients with coronary artery disease is uncertain. STUDY DESIGN: Randomized clinical trial testing the effect of renal artery stenting versus medical therapy on left ventricular hypertrophy progression in patients affected by ischemic heart disease and renal artery stenosis. SETTING & PARTICIPANTS: Incident patients with ischemic heart disease undergoing cardiac catheterization with renal artery stenosis >50%-≤80%. INTERVENTION: Revascularization plus standard medical therapy versus medical therapy alone. OUTCOMES: Primary end point was change in echocardiographic left ventricular mass index (LVMI). MEASUREMENTS: Clinical and echocardiographic studies were performed at baseline and after 1 year. RESULTS: 84 patients were randomly assigned: 43 to revascularization plus standard medical therapy and 41 to medical therapy alone. At baseline, clinical characteristics were similar in the 2 study groups. After 1 year, there was no statistically significant difference between longitudinal change in the medical therapy group versus that in the medical therapy plus revascularization group for LVMI (2.1; 95% CI, -6.1 to 10.3 g/m(2)), blood pressure (systolic, -0.2 [95% CI, -9.1 to 8.8 mm Hg]; diastolic, -3.3 [95% CI, -8.4 to 1.8 mm Hg]), or estimated glomerular filtration rate (1.5; 95% CI, -5.8 to 8.9 mL/min/1.73 m(2)). The number of major cardiovascular events was similar in the 2 groups (revascularization plus standard medical therapy [fatal, n = 2; nonfatal, n = 11] and medical therapy alone [fatal, n = 2; nonfatal, n = 11]). LIMITATIONS: Patients with very severe renal artery stenosis were excluded from the study. CONCLUSIONS: Our study was unable to detect a clinically significant benefit of renal revascularization on LVMI in patients with coronary artery disease and renal artery stenosis of 50%-80%.

[Multislice computed tomographic angiography in the assessment of central veins for endovascular treatment planning: comparison with phlebography]. / Angio-TC MS nello studio dei vasi venosi centrali per la pianificazione del trattamento endovascolare: studio comparativo con la flebografia.

The dysfunction of a vascular access for hemodialysis and its loss may depend on drainage difficulties of the superficial or deep venation due to hemodynamically significant stenosis or obstruction of a central vein, which generally involve the innominate-subclavian veins or superior vena cava. These alterations are often neglected due to their central and deep location; when there is hemodynamic compensation, they may remain asymptomatic. For these reasons every suspect clinical sign for central vein stenosis (gross arm syndrome or venous hypertension in an arteriovenous fistula) must not be ignored, as timely intervention is essential for functional recovery of the vessel and for the protection of the arteriovenous fistula. The modern imaging techniques ensure thorough diagnostic assessment, while the possibilities of endovascular treatment with interventional radiology allow, in a large proportion of cases, optimal minimally invasive treatment, but above all the recovery of venation in a hemodialyzed patient. We report our experience with multislice computed tomographic angiography (MS-CTA) and reconstruction software for treatment planning of central vein stenosis or obstruction. Forty-nine patients were studied with MS-CTA (GE 16). Images were acquired in the venous phase (120-180 seconds after contrast medium injection) followed by digital vascular reconstruction (AutoBone for bone removal, vessel analysis for caliber and length measurements, thin and curved MIP, MPR). Within a week control phlebography was performed. The venous tree was divided into seven segments and analyzed in a double-blind fashion with a distinction between patent segments, 50-70% stenosis, >70% stenosis, occlusion, and collateral vascular beds. There was excellent correspondence in all the examined segments for patency, >70% stenosis, and occlusion, with high sensitivity (98%), specificity (99.3%), and diagnostic accuracy (99.1%). The binomial test demonstrated a highly significant concordance (alpha=0.99) for all patients and in all vascular segments with the exception of 70% stenoses, in which MS-CTA gave a slight overestimate. In the central venous district, color Doppler ultrasonography may not be as effective as for the peripheral study of arteriovenous fistulae, and second-level imaging techniques such as MS-CTA are more useful. We suggest that endovascular treatment must be preceded by MS-CTA. This examination shows the lesions that may benefit from endovascular treatment and recognizes ''uncrossable'' lesions, ie, the ones that will not benefit from treatment. Moreover, it allows accurate planning of endovascular treatment by showing the lesion type (stenosis or obstruction), the position and extension of the involved vessels, the vessel caliber above and below the lesion, and the possible presence of a collateral vascular bed. MS-CTA with dedicated reconstruction software, if correctly performed and accurately reconstructed, is a precious tool for diagnosis and treatment planning.

Stenting of renal artery stenosis in coronary artery disease (RAS-CAD) study: a prospective, randomized trial.

INTRODUCTION: Atherosclerotic renal artery stenosis (RAS) is associated with premature cardiovascular (CV) events and entails a high mortality risk in patients with coronary artery disease (CAD). The effect of renal revascularization on left ventricular mass is not known. AIM: The Stenting of Renal Artery Stenosis in Coronary Artery Disease (RAS-CAD) study is a randomized trial designed to study the effect of medical therapy alone versus medical therapy plus renal artery stenting, on left ventricular hypertrophy progression (primary end point), and CV morbidity and mortality (secondary end points), in patients affected by ischemic heart disease and RAS. METHODS: From April 2006 on, all consecutive patients undergoing nonemergent coronary angiography at a single institution are also to be evaluated for RAS by selective renal arteriography. Patients with RAS>50% and

[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.

Drug-eluting balloon for the treatment of failing hemodialytic radiocephalic arteriovenous fistulas: our experience in the treatment of juxta-anastomotic stenoses.

PURPOSE: The purpose of this article is to report our experience with drug-eluting balloons for the treatment of juxta-anastomotic stenoses of failing radiocephalic hemodialytic arteriovenous shunt and to evaluate the primary and secondary patency (PP and SP). METHODS: After approval by the local hospital's Ethical and Scientific Review Board, 26 consecutive patients with juxta-anastomotic stenosis of radiocephalic hemodialytic shunt were treated with angioplasty with drug-eluting balloon. The main objective was to evaluate PP defined, in accordance with the Kidney Disease Outcomes Quality Initiative recommendation, as the absence of dysfunction of the vascular access, patent lesion or residual stenosis <30% and no need for further reintervention of the target lesion (TL). PP and SP at 6, 12 and 24 months were evaluated, with echo color doppler and phlebography, for both arteriovenous fistulae, defined as absolute, and TL. RESULTS: Immediate postprocedural technical and clinical success was 100% for all the patients; we had only one technical failure in repeated treatments. At 6 months the absolute and TL PP was 96.1%; at 12 months the absolute PP was 81.8%, TL PP 90.9%, absolute SP 95.4%, TL SP 100%; at 24 months the absolute and TL PP was 57.8%; absolute and TL SP 94.7%; only one arteriovenous fistula was lost during the period. CONCLUSIONS: The use of drug-eluting balloons, after standard angioplasty, improves primary patency and decreases reinterventions of TL in juxta-anastomotic stenoses of failing native dialytic arteriovenous shunts.

Discovery of new risk loci for IgA nephropathy implicates genes involved in immunity against intestinal pathogens.

We performed a genome-wide association study (GWAS) of IgA nephropathy (IgAN), the most common form of glomerulonephritis, with discovery and follow-up in 20,612 individuals of European and East Asian ancestry. We identified six new genome-wide significant associations, four in ITGAM-ITGAX, VAV3 and CARD9 and two new independent signals at HLA-DQB1 and DEFA. We replicated the nine previously reported signals, including known SNPs in the HLA-DQB1 and DEFA loci. The cumulative burden of risk alleles is strongly associated with age at disease onset. Most loci are either directly associated with risk of inflammatory bowel disease (IBD) or maintenance of the intestinal epithelial barrier and response to mucosal pathogens. The geospatial distribution of risk alleles is highly suggestive of multi-locus adaptation, and genetic risk correlates strongly with variation in local pathogens, particularly helminth diversity, suggesting a possible role for host-intestinal pathogen interactions in shaping the genetic landscape of IgAN.

Venae comitantes as a potential vascular resource to create native arteriovenous fistulae.

PURPOSE: The arteriovenous fistula (AVF) represents the gold standard for hemodialysis (HD) vascular access. In some critical cases, use of the deep venous circle may represent an alternative approach and venae comitantes could be employed for this purpose. METHODS: Sixty patients with chronic renal failure in which the deep venous circle was used to create an AVF were identified; of the 48 who had a direct anastomosis between the brachial artery and vena comitans, 42 had a long-term follow-up (mean follow-up 59 weeks), while six were lost to follow-up. RESULTS: Immediate success (patency and palpable thrill) was achieved in 88% of cases (primary and early failure 12%). Primary accessibility rate was 62%, while 11 patients required a second surgical approach to make the vein accessible to needling. Secondary accessibility rate of 71% was due to surgical revisions. In the 80-week observation period, the complication rate was 10% with irreversible loss of the AVF in all these cases. Cumulative patency was 71% at the 80th week. Including all 42 patients, technical and functional success rate, defined as vein accessibility to needling and chance of an adequate HD treatment, was 62%. CONCLUSIONS: AVF employing venae comitantes may represent a suitable alternative in the absence of other vascular accesses for HD.

Atypical placement of hemodialysis catheters in patients with complete and irreversible obstruction of central venous vessels.

PURPOSE: This article describes the approach to atypical placement of central venous catheters (CVC) in dialysis patients with complete untreatable obstruction of central venous vessels. METHODS: Five patients with complete obstruction of central venous vessels underwent CT venography and digital venous angiography. After ultrasound-guided and radioscopic-assisted cannulation of the internal jugular vein, permanent CVCs were placed in atypical locations: in two patients a preliminary venous angioplasty was performed to facilitate the catheter positioning in a mediastinal enlarged collateral vein and in a persistent left superior vena cava; in three patients the CVC was placed in the azygos vein, enlarged because of the obstruction of the superior vena cava. RESULTS: In all cases, we achieved satisfactory morphological and functional immediate results. Hemodialysis (HD) was carried out long term in all patients except one who presented a non-functioning CVC after 4 months. In one case the catheter, still functioning well after 9 months, was removed due to kidney transplantation. The CVC in the left superior vena cava was replaced with a longer one after 12 months, and it is still functioning well 3 months after replacement. The patency of the other two catheters has to date been kept for 9 and 18 months. CONCLUSIONS: The placement of CVC for HD in atypical sites can be considered a viable option in extreme cases; adequate imaging support is paramount in order to facilitate the procedure and to avoid complications.

Diabetic polyneuropathy in mild renal failure: recovery with gangliosides

A polineuropatia é umas das mais importantes complicaçöes do diabetes tipo 1 e 2. O tratamento desta patologia permanece infrutífero. Descrevemos aqui dois casos tratados com altas doses de gangliosídeos por tempo prolongado. Dois pacientes com diabetes tipo 2 foram tratados com 100mg de ganglosideos, duas vezes por semana e durante 30 meses. Os pacientes apresentavam polineuropatia sensitivo-motor e autonômica, com manifestaçöes clínicas importantes e alteraçöes eletromiográficas específicas. Umas melhora significante foi obtida após 18 meses de tratamento com recuperaçäo total dos sinais e sintomas após 25 a 30 meses. Estes resultados sugerem que o tratamento a longo prazo e com altas doses de gangliosídeos é capaz de promover um resultado clínico favorável na polineuropatia diabética após 18 meses de medicaçäo e que uma recuperaçäo completa pode ser obtida após 30 meses. Esta estratégia terapêutica pode ser considerada como relevante dado o consequente aumento da taxa de sobrevida de pacientes diabéticos