Cancer therapy in patients with reduced kidney function.

Chronic Kidney Disease (CKD) and cancer constitute two major public health burdens and are on the rise. Moreover, the number of patients affected simultaneously by both conditions is growing. Potential nephrotoxic effect of cancer therapies is particularly important for patients with CKD, as they are also affected by several comorbidities. Therefore, administering the right therapy at the right dose for patients with decreased kidney function can represent a daunting challenge. We review in detail the renal toxicities of anti-cancer therapies i.e. conventional chemotherapy, targeted therapy, immune checkpoint inhibitors, and radioligand therapies, issue recommendations for patient monitoring along with guidance on when to withdraw treatment and suggest dosage guidelines for select agents in advanced stage CKD. Various electrolytes disturbances can occur as the result of the administration of anti-cancer agents in the patient with decreased kidney function. These patients are prone to developing hyponatremia, hyperkalemia, and other metabolic abnormalities because of a decreased GFR. Therefore, all electrolytes, minerals and acid base status should be checked at baseline and before each administration of chemotherapeutic agents. Moreover, studies on patients on kidney replacement therapy (KRT) are very limited and only single cases or small case series are published. Therefore, clinical therapeutical decisions in cancer patients with decreased function should be made by multidisciplinary teams constituted of medical oncologists, nephrologists, and other specialists. Onconephrology is an evolving and expanding subspecialty. It is crucial to consider anticancer drug treatment in these patients and offer them a chance to be treated effectively.

Hypoxia-inducible factor prolyl hydroxylase inhibitors for anaemia in chronic kidney disease: a document by the European Renal Best Practice board of the European Renal Association.

Anaemia is a common complication of chronic kidney disease (CKD) and is associated with poor long-term outcomes and quality of life. The use of supplemental iron, erythropoiesis stimulating agents (ESAs) and blood transfusions has been the mainstay of treatment of anaemia in CKD for more than three decades. Despite available treatments, CKD patients with anaemia are undertreated and moderate-to-severe anaemia remains prevalent in the CKD population. Anaemia has consistently been associated with greater mortality, hospitalisation, cardiovascular events, and CKD progression in patients with CKD, and the risk increases with anaemia severity. Hypoxia-inducible factor (HIF) prolyl hydroxylase (PH) inhibitors have a novel mechanism of action by mimicking the body's response to hypoxia and have emerged as an alternative to ESAs for the treatment of anaemia in CKD. Their efficacy in correcting and maintaining haemoglobin has been demonstrated in over 30 phase 3 clinical trials. Additionally, HIF activation results in various pleiotropic effects beyond erythropoiesis with cholesterol reduction and improved iron homeostasis and potential anti-inflammatory effects. The long-term safety of these agents, particularly with respect to cardiovascular and thromboembolic events, and their possible effect on tumor growth requires to be fully elucidated. This document presents in detail the effects of HIF-PH inhibitors, describes their mechanisms of action and pharmacologic properties, and discusses their place in the treatment of anaemia in CKD according to the available evidence.

Efficacy of erythropoietin as a neuroprotective agent in CKD-associated cognitive dysfunction: A literature systematic review.

Patients with chronic kidney disease (CKD) often experience mild cognitive impairment and other neurocognitive disorders. Studies have shown that erythropoietin (EPO) and its receptor have neuroprotective effects in cell and animal models of nervous system disorders. Recombinant human EPO (rHuEPO), commonly used to treat anemia in CKD patients, could be a neuroprotective agent. In this systematic review, we aimed to assess the published studies investigating the cognitive benefits of rHuEPO treatment in individuals with reduced kidney function. We comprehensively searched Pubmed, Cochrane Library, Scopus, and Web of Science databases from 1990 to 2023. After selection, 24 studies were analyzed, considering study design, sample size, participant characteristics, intervention, and main findings. The collective results of these studies in CKD patients indicated that rHuEPO enhances brain function, improves performance on neuropsychological tests, and positively affects electroencephalography measurements. These findings suggest that rHuEPO could be a promising neuroprotective agent for managing CKD-related cognitive impairment.

Real-World Treatment of Hypertension on Hemodialyses Data from a Large Polish Database.

INTRODUCTION: The prevalence of hypertension among patients with end-stage kidney disease (ESKD) undergoing hemodialysis (HD) ranges from 72 to 88% depending on applied diagnostic criteria and the chosen method of blood pressure measurement. Despite the guidelines recommending the widespread use of renin-angiotensin system blockers (RASBs) in patients with kidney disease, their utilization in patients on HD may be suboptimal, especially in patients with preserved diuresis. This hesitance that often steams from concern is often due to fear of a decrease in eGFR and a subsequent decrease in diuresis. The aim of this study was to compare clinical characteristics, blood pressure, safety, and HD adequacy indices in hypertensive HD patients on multiple antihypertensive drug regimens, including diuretic treated with RASB (RASB group) or without RASB (no-RASB) with preserved residual diuresis. We sought to examine the real-life use of RASB in HD patients in relation to their clinical characteristics, blood pressure, safety, and HD adequacy. METHODS: From a database of 5,879 patients receiving HD (mean age 65.2 ± 14.2 years, 60% of males) of the largest provider of HD in the country, we selected the subgroup treated with at least three antihypertensive medications including diuretics. We compared patients treated with RASB to counterparts without RASB (no-RASB). RESULTS: The RASB group has similar age and gender proportions as well as BMI and bioimpedance compared to counterparts. However, dry body mass was significantly lower in the RASB group (78.1 ± 18.3 kg vs. 80.0 ± 18.2 kg, p < 0.017). Prevalence of diabetes mellitus was similar in both groups, but RASB-treated patients have cardiovascular diseases more frequently (70.1 vs. 60.8%; p < 0.001). Systolic blood pressure and the number of antihypertensive drugs used were significantly higher in RASB patients than in counterparts (146 ± 16 mm Hg vs. 144 ± 15 mm Hg; p < 0.001 and 4.1 ± 0.9 vs. 3.5 ± 0.5; p < 0001, respectively). RASB-treated patients have significantly longer dialysis vintage (52.7 ± 44.4 months vs. 40.2 ± 40.9 months; p < 0.001) and dialysis time (722 ± 87.1 min/week vs. 713 ± 93.4 min/week; p < 0.017) than counterparts. Serum potassium was slightly but significantly higher in RASB (5.3 ± 0.8 mmol/L vs. 5.1 ± 0.7 mmol/L; p < 0.01). CONCLUSIONS: In the real world setting, RASB can be safely used in HD patients treated with diuretics with preserved residual diuresis. Given that many HD patients present numerous multimorbidities, RASB should not only be considered as an additional hypotensive drug in poorly controlled hypertension but also in other compelling indications in HD patients. The tendency toward hyperkalemia in HD patients could be effectively managed with appropriate diet and HD prescription adjustments.

The Clock Drawing Task reveals executive dysfunction in the dialysis population - an underrecognized and underestimated problem.

AIM OF THE STUDY: The study aimed to assess the prevalence of executive function impairment among patients with chronic kidney disease (CKD) undergoing dialysis, with no subjective cognitive problems and with normal global cognition on the Mini-Mental State Examination (MMSE). We also investigated the relationship between cardiovascular risk factors and cognitive test results. RATIONALE FOR THE STUDY: Patients with CKD, including those undergoing renal replacement therapy, are at a higher risk of developing cognitive impairment (CI) than the general population. Recent research has shown CI to be a growing problem among CKD patients worldwide. Yet, it remains underdiagnosed, even though it may significantly influence the lives of patients. MATERIALS AND METHODS: In this cross-sectional, prospective study, 58 dialysis patients with no cognitive decline on the MMSE screening were assessed for executive function impairment using the Executive Clock-Drawing Task (CLOX). Moreover, past medical history, demographic data, and laboratory test results were collected. RESULTS: The mean patient age was 59.47 ± 14.98 years, and the mean duration of dialysis was 45.93 ± 48.49 months. The prevalence of executive function impairment amounted to 8.6%. Moreover, remarkably similar pattern of clock drawing was observed, with numbers written outside the clock face in the CLOX1 test. CONCLUSIONS: Executive dysfunctions in dialysis patients may manifest itself before the onset of global cognitive impairment. There appear to be a deficit in the spatial domain as well. Better education may play a protective role.

Differences in mortality and risk factors, two years after endovascular repair of ruptured abdominal aortic aneurysms - Reassessment analysis.

OBJECTIVE: The prevalence of abdominal aortic aneurysms (AAA) increases with age. Elective intervention for AAA is critical to prevent rupture associated with very high mortality among older males. METHODS: The aim of this study was to address the impact of post-contrast acute kidney-PC-AKI injury among patients treated with endovascular repair of ruptured AAA-EVAR on outcomes such as new onset chronic kidney disease-CKD and mortality among patients within a two-year trial. RESULTS: The same study group (of n = 192 patients) underwent reassessment, two years after EVAR treatment. The overall mortality rate was 16.67%, and it was higher in the AKI group - 38.89%. CKD patients had a mortality rate of 23.88% (n = 16). Among patients with an aneurysm diameter >67 mm mortality rate reached 20% (n = 6), while in the previously reported diabetes mellitus group 37.93% (n = 11). New onset of CKD was diagnosed in 23% of cases. Preexisting CKD patients with PC- AKI contributed to a 33.33% mortality rate (n = 8). CONCLUSION: This study concludes that PC-AKI impacts outcomes and survival in endovascularly treated AAAs. Type 2 diabetes and preexisting chronic kidney disease are associated with higher mortality within a 2-year follow-up, however gender factor was not significant. A larger aneurysm diameter is related with a higher prevalence of PC-AKI. These factors should be taken into account during screening, qualifying patients for the treatment and treating patients with AAA. It may help to identify high-risk individuals and tailor preventive measurements and treatment options accordingly, improving treatment results and reducing mortality.

Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.

Resistant hypertension in dialysis.

Hypertension is the most common finding in chronic kidney disease patients, with prevalence ranging from 60% to 90% depending on the stage and etiology of the disease. It is also a significant independent risk factor for cardiovascular disease, progression to end-stage kidney disease and mortality. According to the current guidelines, resistant hypertension is defined in the general population as uncontrolled blood pressure on three or more antihypertensive drugs in adequate doses or when patients are on four or more antihypertensive drug categories irrespective of the blood pressure control, providing that antihypertensive treatment included diuretics. The currently established definitions of resistant hypertension are not directly applicable to the end-stage kidney disease setting. The diagnosis of true resistant hypertension requires confirmation of adherence to therapy and confirmation of uncontrolled blood pressure values by ambulatory blood pressure measurement or home blood pressure measurement. In addition, the term "apparent treatment-resistant hypertension," defined as an uncontrolled blood pressure on three or more antihypertensive medication classes, or use of four or more medications regardless of blood pressure level was introduced. In this comprehensive review we focused on the definitions of hypertension, and therapeutic targets in patients on renal replacement therapy, including the limitations and biases. We discussed the issue of pathophysiology and assessment of blood pressure in the dialyzed population, management of resistant hypertension as well as available data on prevalence of apparent treatment-resistant hypertension in end-stage kidney disease. To conclude, larger sample-size and even higher quality studies about drug adherence should be conducted in the population of patients with the end-stage kidney disease who are on dialysis. It also should be determined how and when blood pressure should be measured in the group of dialysis patients. Additionally, it should be stated what the target blood pressure values in this group of patients really are. The definition of resistant hypertension in this group should be revisited, and its relationship to both subclinical and clinical endpoints should be established.

Malignancies in adult kidney transplant candidates and recipients: current status.

Posttransplant malignancies, particularly recurrent and de novo, in solid organs including kidney transplant recipients (KTRs) are a significant complication associated with substantial mortality, largely attributed to the long-term immunosuppression necessary to maintain allograft tolerance. Older age at transplantation and oncogenic virus infection along with pretransplant malignancies are among the main factors contributing to the risk of cancer in this population. As the mean age of transplant candidates rises, the rate of transplant recipients with pretransplant malignancies also increases. The eligibility criteria for transplantation in patients with prior cancer have recently changed. The overall risk of posttransplant malignancies is at least double after transplantation, including KTRs, relative to the general population, and is most pronounced for skin cancers associated with UV radiation and virally mediated tumors. The risk of renal cell carcinoma is specifically increased in the kidney transplant population. The therapy for cancer in transplant patients is associated with risk of higher toxicity, and graft rejection and/or impairment, which poses a unique challenge in its management. Reduction of immunosuppression and the use of mammalian target of rapamycin inhibitors are common after cancer diagnosis, although optimal immunosuppression for transplant recipients with cancer remains undefined. Suboptimal cancer treatment contributing to a worse prognosis has been reported for malignancies in this population. In this article, we focus on the prevalence and outcomes of posttransplant malignancies, cancer therapy including a short overview of immunotherapy, cancer screening and prevention strategies, and immunosuppression as a cancer risk factor. The 2020/2021 recommendations of the Kidney Disease: Improving Global Outcomes and the American Society of Transplantation for transplant candidates with a history of cancer are presented.

Cognitive disorders in patients with chronic kidney disease: Approaches to prevention and treatment.

BACKGROUND: Cognitive impairment is common in patients with chronic kidney disease (CKD), and early intervention may prevent the progression of this condition. METHODS: Here, we review interventions for the complications of CKD (anemia, secondary hyperparathyroidism, metabolic acidosis, harmful effects of dialysis, the accumulation of uremic toxins) and for prevention of vascular events, interventions that may potentially be protective against cognitive impairment. Furthermore, we discuss nonpharmacological and pharmacological methods to prevent cognitive impairment and/or minimize the latter's impact on CKD patients' daily lives. RESULTS: A particular attention on kidney function assessment is suggested during work-up for cognitive impairment. Different approaches are promising to reduce cognitive burden in patients with CKD but the availabe dedicated data are scarce. CONCLUSIONS: There is a need for studies assessing the effect of interventions on the cognitive function of patients with CKD.

Cognitive Impairment and Anxiety Are Prevalent in Kidney Transplant Recipients.

INTRODUCTION: Cognitive impairment (CI) is common in end-stage kidney disease (ESKD), including kidney transplant recipients. Patients with cognitive problems may find it difficult to comply with medical recommendations after kidney transplantation (KT), which can be the cause of many complications, poorer prognosis, and increased hospitalization rates after transplantation. Additionally, some patients after KT may experience depression and anxiety, which are prevalent comorbidities in patients with ESKD. METHODS: In this single-center, cross-sectional study, we included 56 consecutive adult patients after KT. Cognitive function was assessed using the Addenbrooke Cognitive Test III (ACE III). In addition, all patients were screened for depression and anxiety using the Hospital Anxiety and Depression Scale (HADS). The impact of immunosuppressive therapy and other disease-related variables on cognitive function was also assessed. RESULTS: A total of 56 KT patients, with a mean age of 50.3 ± 11.7 years, transplanted ≤35 months ago were included in the study. The prevalence of CI was 30%. Compared with cognitively unimpaired patients, patients with CI scored significantly lower in all cognitive domains. Furthermore, better cognitive functioning after KT was significantly associated with more years of schooling. We found no significant correlation between CI and age at assessment, duration of dialysis before KT, creatinine levels, creatinine clearance, uric acid levels, hemoglobin levels, comorbid cardiovascular diseases, and immunosuppressive therapy. In addition, the prevalence of depression and anxiety in screening tests was 12.5% and 27%, respectively, and patients receiving higher daily dose of prednisone had higher HADS scores on both the depression and anxiety subscales (not statistically significant). DISCUSSION: Cognitive disorders are a relevant issue in kidney transplant recipients. There might be many factors, both before and after KT, that have a negative impact on cognition. Therefore, further research is needed to increase knowledge about the course and profile of cognitive function after KT.

Prevalence of Cognitive Impairment in Peritoneal Dialysis Patients and Associated Factors.

BACKGROUND: Cognitive impairment (CI) in patients with chronic kidney disease, including those treated with renal replacement therapy, is a growing problem worldwide. OBJECTIVES: The study aimed to assess the prevalence of CI and associated factors in patients undergoing peritoneal dialysis (PD). METHODS: In this cross-sectional study, 18 consecutive patients with PD therapy and 15 controls were evaluated for CI using the Addenbrooke's Cognitive Examination III (ACE III) test. RESULTS: The prevalence of CI was 33% in patients and 27% in the control group and was not statistically significant. A higher prevalence of CI was found in subjects aged ≥65 years old than in those <65 years old (p = 0.02), but only in the control group. The prevalence of CI in PD patients over and under 65 years of age did not differ statistically significantly (p = 0.12). Memory and verbal fluency were the most affected cognitive domain in PD patients with CI (p = 0.00, p = 0.04, respectively). There was a significant correlation between higher educated PD patients and the ACE III test results. The duration of dialysis did not affect the results of the cognitive screening test. CONCLUSIONS: CI is a growing problem in the course of chronic kidney disease and dialysis therapy. It seems that cognitive problems may occur in patients undergoing PD at a younger age than in the general population with particularly affected memory and verbal fluency. Higher educated patients score better on the cognitive screening test.

Green Dialysis: Let Us Talk about Dialysis Fluid.

BACKGROUND: Hemodialysis is one of the most resources consuming medical intervention. Due to its concept, the proper amount of dialysis fluid passed through dialyzer is crucial to obtain the expected outcomes. The most frequent source of dialysis fluid is production from liquid concentrate (delivered in containers or plastic bags) in dialysis machine. Alternatively, concentrates for dialysis may be produced in dialysis center by dilution in mixing devices dry or semidry premixed compounds connected with system of central dialysis fluid delivery system. Dialysate consumption depends on various factors like type of hemodialysis machine, session duration, prescribed flow, etc. Summary: Modern hemodialysis machines are equipped with the modules which automatically reduce flow rate of dialysis fluid to the patient blood flow and minimize dialysate consumption during preparation and after reinfusion. Smart using of available options offered by manufacturers allows to save additional portion of acid concentrate and water. The weight of concentrates to be delivered to the dialysis center is the major factor influencing the cost (financial and environmental) of transportation from the manufacturer to the final consumer. The crisis on the energy carriers market and extremely high fuel prices made the transportation cost one of the significant costs of the treatment, which must be bear by supplier and finally influence on the price of goods. KEY MESSAGES: The careful choice of the concentrate delivery system can improve cost-effectiveness of dialysis. Such solutions implemented in dialysis unit helps make significant savings and decrease the impact on natural environment by carbon footprint reduction.

The prevalence of anemia in people with chronic kidney disease after hematopoietic stem cell transplantation.

The hematopoietic stem cell transplantation (HSCT) is performed for various hematological diseases. Chronic kidney disease (CKD) occurs relatively often after HSCT. Anemia after HSCT may be due to CKD and/or other reasons. The aim of this study is to assess the prevalence of anemia and its possible relationship to the presence of CKD in patients at least 3 months after HSCT. The study included 156 patients who underwent allogeneic HSCT treatment in our center in the years 1998 to 2021 due to different hematologic pathologies (acute myeloid leukemia, acute lymphoblastic leukemia, lymphoma, and others). Anemia was diagnosed in 13% of women and 35% of men. Anemia was most common in people after HSCT due to a history of acute myeloid leukemia (55% women, 30% men). In 56% of women and 17% of men, anemia was associated with chronic kidney disease. In patients with anemia, age was related to the eGFR (r = -0.39, p < 0.001), in patients without anemia age was negatively related to eGFR (r = -0.56, p < 0.001), and hemoglobin was positively related to platelet count (r = 0.62, p < 0.001). Concluding, anemia, was relatively common in CKD after HSCT. In CKD, in particular with coexistent anemia, nephrology referral is to be taken into account to optimize therapy, including nephroprotection.

Proenkephalin Levels and Its Determinants in Patients with End-Stage Kidney Disease Treated with Hemodialysis and Peritoneal Dialysis.

Recently, proenkephalin A (PENK A) has been shown to reflect glomerular dysfunction and to predict new-onset acute kidney injury and heart failure. While previous studies have investigated PENK A as a biomarker in individuals with preserved renal function, PENK A concentration in patients with end-stage kidney disease (ESKD) was not investigated. Plasma PENK A concentration was assessed in 88 patients with ESKD treated with hemodialysis (HD) or peritoneal dialysis (PD), and its associations with kidney function and heart failure indicators were investigated. In HD patients, the difference in PENK A levels before and after hemodialysis, was measured and further assessed for an association with the type of HD membrane used. PENK A levels did not differ significantly between HD and PD patients. In HD patients, the median PENK A concentration was significantly higher before than after hemodialysis (1.368 vs. 2.061, p = 0.003). No correlation was found between PENK A level and urea (p = 0.192), eGFR (p = 0.922), dialysis vintage (p = 0.637), and residual urine output (p = 0.784). Heart failure (p = 0.961), EF (p = 0.361), and NT-proBNP (p = 0.949) were not associated with increased PENK A concentration. PENK A does not reflect renal function and cardiac status in patients with ESKD. Further research is required to establish the clinical utility of the new biomarker in patients with impaired kidney function.

Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference.

The diagnosis and management of atherosclerotic renovascular disease (ARVD) is complex and controversial. Despite evidence from the ASTRAL (2009) and CORAL (2013) randomized controlled trials showing that percutaneous renal artery revascularization did not improve major outcomes compared with best medical therapy alone over 3-5 years, several areas of uncertainty remain. Medical therapy, including statin and antihypertensive medications, has evolved in recent years, and the use of renin-angiotensin-aldosterone system blockers is now considered the primary means to treat hypertension in the setting of ARVD. However, the criteria to identify kidneys with renal artery stenosis that have potentially salvageable function are evolving. There are also data suggesting that certain high-risk populations with specific clinical manifestations may benefit from revascularization. Here, we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.

Haematological disorders following kidney transplantation.

Transplantation offers cure for some haematological cancers, end-stage organ failure, but at the cost of long-term complications. Renal transplantation is the best-known kidney replacement therapy and it can prolong end-stage renal disease patient lives for decades. However, patients after renal transplantation are at a higher risk of developing different complications connected not only with surgical procedure but also with immunosuppressive treatment, chronic kidney disease progression and rejection processes. Various blood disorders can develop in post-transplant patients ranging from relatively benign anaemia through cytopenias to therapy-related myelodysplasia and acute myeloid leukaemia (AML) and post-transplant lymphoproliferative disorders followed by a rare and fatal condition of thrombotic microangiopathy and haemophagocytic syndrome. So far literature mainly focused on the post-transplant lymphoproliferative disease. In this review, a variety of haematological problems after transplantation ranging from rare disorders such as myelodysplasia and AML to relatively common conditions such as anaemia and iron deficiency are presented with up-to-date diagnosis and management.

Cognitive Impairment and Kidney Transplantation: Underestimated, Underrecognized but Clinically Relevant Problem.

BACKGROUND: Chronic kidney disease (CKD) affects the crosstalk between organs in the body and vast majority of studies were devoted to the interactions between the kidneys and the cardiovascular system. As of today, there is more evidence of the kidney and the central nervous system connections. SUMMARY: Indeed, CKD and in particular dialysis therapy is linked to the increased prevalence of neurological complications, such as cerebrovascular disorders, movement disorders, cognitive impairment, and depression. Both traditional cardiovascular risk factors (such as diabetes, hypertension, and lipid disorders), nontraditional risk factors (such as uremic toxins, anemia, and secondary hyperparathyroidism) may predispose CKD patients to neurological disorders. Likewise, cognitive problems occur more commonly in kidney transplant recipients, regardless of age, than in the general population, but the prevalence is still understudied. Cognitive impairment is associated with a higher risk of hospitalization, mortality, decreased quality of life, or health care costs in kidney transplant recipients. Here, we review (i) the potential clinical impact of kidney transplantation on cerebrovascular and neurological complications, (ii) evaluation of patients with cognitive impairment for kidney transplantation (iii) the potential impact of cognitive impairment on waitlisted and transplanted patients on patient care, and (iv) unmet medical needs. KEY MESSAGES: Cognitive impairment in kidney transplant recipients is an underestimated, underrecognized but clinically relevant problem. The screening for cognitive declines after kidney transplantation is not yet a routine practice. Several prospective and cross-sectional studies reported improvement across some of the assessed cognitive domains after transplantation.

Retroperitoneal Fibrosis Is Still an Underdiagnosed Entity with Poor Prognosis.

BACKGROUND: Retroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of inflammatory and fibrous retroperitoneal tissue that often encircles abdominal organs including the aorta and ureters. Data on the incidence of this disease are limited. SUMMARY: The disease may be idiopathic or secondary to infections, malignancies, drugs, or radiotherapy. The idiopathic form is an immune-mediated entity and a part of the broader spectrum of idiopathic diseases termed chronic periaortitis, characterized by a morphologically similar fibroinflammatory changes in the aorta and surrounding tissues. Taking into account the dominant symptoms and clinical characteristics of patients with periaortitis, 2 subtypes of disease could be distinguished. The vascular subtype includes patients with nondilated aorta or with inflammatory abdominal aortic aneurysm, both with and without involvement of adjacent structures and with numerous risk factors for atherosclerosis. In the renoureteral subtype, obstructive uropathy manifesting with hydronephrosis and acute kidney injury is the predominant finding. Due to the variety of symptoms, diagnosis of RPF remains challenging, difficult, and often delayed. A series of diagnostic tests should be performed, in order to confirm the diagnosis idiopathic RPF. Laboratory workup includes evaluation of inflammatory indices and immunological studies. A biopsy and histopathological evaluation may be necessary to confirm diagnosis and differentiate the disease. Computed tomography, magnetic resonance imaging, and positron emission tomography are the modalities of choice for the diagnosis and follow-up of this disease. Management of ureteral obstruction, hydronephrosis, and aortic aneurysms often requires surgical evaluation and treatment. The pharmacological treatment of RPF has been evaluated in a few randomized trials and is mainly based on observational studies. Steroid therapy remains the gold standard of treatment. KEY MESSAGES: Nowadays, multidisciplinary team approach with clinical and diagnostic experience in both primary and secondary RPF as well as 2 major subtypes should be offered. Centers specialized in rare diseases with collaboration with other units and referral system yield the best possible outcomes.

Acid-base balance in hemodialysis patients in everyday practice.

INTRODUCTION: Abnormalities in blood bicarbonates (HCO3-) concentration are a common finding in patients with chronic kidney disease, especially at the end-stage renal failure. Initiating of hemodialysis does not completely solve this problem. The recommendations only formulate the target concentration of ≥22 mmol/L before hemodialysis but do not guide how to achieve it. The aim of the study was to assess the acid-base balance in everyday practice, the effect of hemodialysis session and possible correlations with clinical and biochemical parameters in stable hemodialysis patients. MATERIAL AND METHODS: We enrolled 75 stable hemodialysis patients (mean age 65.5 years, 34 women), from a single Department of Nephrology. We assessed blood pressure, and acid-base balance parameters before and after mid-week hemodialysis session. RESULTS: We found significant differences in pH, HCO3- pCO2, lactate before and after HD session in whole group (p < 0.001; p < 0.001; p < 0.001; p = 0.001, respectively). Buffer bicarbonate concentration had only statistically significant effect on the bicarbonate concentration after dialysis (p < 0.001). Both pre-HD acid-base parameters and post-HD pH were independent from buffer bicarbonate content. We observed significant inverse correlations between change in the serum bicarbonates and only two parameters: pH and HCO3- before hemodialysis (p = 0.013; p < 0.001, respectively). CONCLUSIONS: Despite the improvement in hemodialysis techniques, acid-base balance still remains a challenge. The individual selection of bicarbonate in bath, based on previous single tests, does not improve permanently the acid-base balance in the population of hemodialysis patients. New guidelines how to correct acid-base disorders in hemodialysis patients are needed to have less 'acidotic' patients before hemodialysis and less 'alkalotic' patients after the session.