[Italian nephrology and the progress of dialysis from its dawn to the present day].

In Italy, over the last 50 years, dialysis has been the driving force of research in nephrology. The work of many Italian nephrologists has fueled progress in dialytic techniques worldwide, improving dramatically the quality of dialytic therapy. Our foreign colleagues unanimously agree that we have been the first to look into the complexities of dialysis, into the many differences between dialytic patients and how to best address this diversity. This has allowed us to adopt a holistic approach, deeply connected to technological innovation, with the aim of putting the patient center stage and creating a "precision dialysis".

[Nephrology : what's new in 2018 ?] / Néphrologie.

Major advances in the treatment of ANCA associated-renal vasculitides, IGA nephropathy and renal autosomal dominant polycystic disease were published within the past year. There is neither clear benefit of early initiation of renal replacement therapy in the intensive care unit nor with the use of chloride-poor solutions to prevent kidney failure. Maintenance parenteral iron supplementation in hemodialysis patients is neither associated with infectious nor cardiovascular risks. Cognitive decline may be more associated with hemodialysis than peritoneal dialysis. In transplantation, the persistence of complement-binding donor-specific antibodies after treatment is predictor of graft loss. Tocilizumab is a promising treatment for chronic antibody-mediated rejection.

Des progrès importants ont été effectués cette année dans le traitement des vascularites rénales à ANCA (anticorps anti-cytoplasme des polynucléaires neutrophiles), de la néphropathie à IgA et de la polykystose rénale. Il n'y a pas d'avantage clair à l'initiation précoce de la dialyse en cas d'insuffisance rénale sévère et à l'utilisation des solutions pauvres en chlore dans le remplissage volémique. En hémodialyse chronique, une supplémentation en fer parentéral jusqu'à 400 mg par mois n'est pas associée à un risque infectieux ou cardiovasculaire augmenté. L'hémodialyse pourrait être associée à un déclin cognitif plus important que la dialyse péritonéale. En transplantation, la persistance d'anticorps dirigés contre le greffon et liant le complément après traitement du rejet, est prédicteur de perte du greffon. Le tocilizumab serait un traitement prometteur du rejet chronique médié par les anticorps.

Integrating kidney transplantation into value-based care for people with renal failure.

Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource-intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project-the Comprehensive ESRD Care (CEC) initiative-to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time-sensitive incentive for transplant centers in particular to align with extant CECs. An "expanded" CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.

The evolving role of the medical director of a dialysis facility.

The medical director has been a part of the fabric of Medicare's ESRD program since entitlement was extended under Section 299I of Public Law 92-603, passed on October 30, 1972, and implemented with the Conditions for Coverage that set out rules for administration and oversight of the care provided in the dialysis facility. The role of the medical director has progressively increased over time to effectively extend to the physicians serving in this role both the responsibility and accountability for the performance and reliability related to the care provided in the dialysis facility. This commentary provides context to the nature and expected competencies and behaviors of these medical director roles that remain central to the delivery of high-quality, safe, and efficient delivery of RRT, which has become much more intensive as the dialysis industry has matured.

The last mile: translational research to improve CKD outcomes.

The National Institute of Diabetes and Digestive and Kidney Diseases-supported Kidney Research National Dialogue asked the scientific community to formulate and prioritize research objectives that would enhance understanding of kidney function and disease and improve clinical outcomes. An engaged and growing group of investigators working in type 2 translation (from clinical evidence to implementation in the community) identified barriers to improving patient care in CKD and suggested research priorities to test translational strategies that have been effective for other chronic diseases.

Toward population management in an integrated care model.

Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative.

Recent trends in hypertension treatment: perspectives from animal studies.

Several newer areas of hypertension research are presented in this supplement. First, the benefits of melatonin in the treatment of experimental hypertension including its cardioprotective effects are introduced. Second, the possible role of melatonin in the non-dipping blood pressure pattern is described. Third, two hypotheses discuss the potential reasons for the ineffectivness of antioxidants in hypertension treatment, and difficulties associated with interpretations of experimental findings in the model of the spontaneously hypertensive rat (SHR). Finally, interactions of indapamide with the nitric oxide system in SHR, the protective effect of angiotensin II type 1 receptor blockade against alterations in insulin-resistant rats, and the deleterious effect of a low protein diet on kidney maturation with the development of hypertension are presented.

Update on the treatment of chronic kidney disease-mineral and bone disorder.

Chronic kidney disease (CKD) is associated with increased morbidity and mortality. Mineral metabolism disturbances appear to contribute to the high mortality rate. A CKD-mineral bone disorder (CKD-MBD) has recently been defined as a systemic disorder manifested by one or a combination of abnormalities in bone biopsy, laboratory parameters and/or vascular or other soft-tissue calcifications. New available treatments have contributed to move from the former treatment paradigm of renal osteodystrophy to CKD-MBD management, beyond mere control of parathyroid hormone (PTH) and trying to improve cardiovascular or survival outcomes. Thus, the recommended multidisciplinary approach among nurses, dieticians and clinicians, helping not only through dietary assessment but also through education, behaviour control and by increasing the patient's personal motivation, may have additional important benefits. This article will review the current therapeutic approach with phosphate binders including the latest developments, vitamin D derivatives and selective vitamin D receptor activators as well as the new calcimimetics, all used in the treatment of this systemic disease.

Soft bones and hard arteries-can we reverse the trend in CKD?

Chronic kidney disease-bone and mineral disorder (CKD-MBD) signifies the complex pathophysiological interactions between calcium, phosphorus and regulatory hormones which are associated, sometimes causally, with impaired bone mineralisation and increased fracture risk in patients with CKD. It also signifies a predisposition to vascular calcification (VC), the emergence of which as a likely side effect of some of the current therapies poses a difficult problem for physicians aiming to treat patients with CKD. This complex disorder has seen several important advances in relation to understanding of the pathophysiology and, it is hoped, refinement of therapeutic approaches.

Oral phosphate binders for the management of serum phosphate levels in dialysis patients.

Hyperphosphataemia is an inevitable consequence of end stage chronic kidney disease and is present in the majority of dialysis patients. Hyperphosphataemia is statistically associated with increased cardiovascular mortality among dialysis patients. Dietary restriction of phosphate and current dialysis modalities are not sufficiently effective to maintain serum phosphate levels within the recommended range so that the majority of dialysis patients require oral phosphate binders. However, benefits of achieving the recommended range have yet to be demonstrated prospectively. Unfortunately, conventional phosphate binders are not reliably effective and are associated with a range of limitations and side effects. Aluminium containing agents are highly efficient but no longer widely used because of well-established and proven toxicity. Calcium-based salts are inexpensive, effective and most widely used but there is now concern about their association with hypercalcaemia and vascular calcification. Sevelamer hydrochloride and lanthanum carbonate are non-aluminium, calcium-free phosphate binders. They are effective and reasonably well tolerated, but still do not control phosphate levels in all patients. Patient education programmes have been shown to be a useful and effective method of improving achievement of serum phosphate targets.

Recent advances in nephrology: highlights from the 35th annual meeting of the American society of nephrology.

The 35th Annual Meeting of the American Society of Nephrology, held in Philadelphia, Pennsylvania, United States (October 30 to November 4, 2002) presented the newest advances in basic and clinical nephrology science. Several presentations and symposia discussed the effects of various interventions and risk factors in clinical outcomes in dialysis patients. The recent evidences of pure red cell aplasia secondary to neutralizing antibodies against erythropoietin were also extensively discussed in a special symposium. Recent advances in the management of calcium phosphorus metabolism and secondary hyperparathyroidism, such as the clinical efficacy and safety of AMG-073, a new calcimimetic agent in the control of hyperparathyroidism in chronic kidney disease patients, or the use of sevelamer or lanthanum carbonate as phosphate binders, were presented. The results in animal models on improved sparing of renal function with rapamycin versus cyclosporin A represent a promising advance in renal transplantation. Finally, the recent discoveries with the newly identified disease gene PKHD1, which causes autosomal recessive polycystic kidney disease, were also presented at the meeting.

Present and future strategies in the treatment of renal anaemia.

Recombinant human erythropoietin therapy has transformed the management of renal anaemia over the last decade or so. We have learned much about the optimum regimens for using this drug, including the route of administration, dosage frequency, use of iron supplementation, and management of poor response. Thus, dosage requirements of epoetin are generally lower if the drug is administered subcutaneously, and the most commonly used dosage frequency is two or three times weekly. The vast majority of patients respond very well to treatment, but approximately 5-10% of patients show some resistance to epoetin, the most common cause of which is iron deficiency. The presence of infection or inflammation and underdialysis are other important causes of a poor response to epoetin. There is increasing interest in treating renal anaemia at an earlier stage in the course of the disease, and there is much circumstantial evidence to support this strategy. This usually involves giving epoetin to pre-dialysis patients, and a study has also recently commenced to investigate the effects of preventing renal anaemia ever developing. Other erythropoietic substances are being developed, and the first of these to be ready for clinical use is novel erythropoiesis stimulating protein (NESP), which is an analogue of erythropoietin containing two extra N-linked carbohydrate side-chains. Other potential erythropoietic substances are still at the laboratory stage of development, but may be available for therapeutic use in the next decade or so.

How to improve survival in pre-dialysis patients.

AIMS: This survey was performed to determine how anaemia in pre-dialysis patients is currently managed. METHODS: A random sample of 200 nephrologists attending the 1999 ERA/EDTA Congress participated in an interactive survey session. Participants were questioned on their current prescribing attitudes and preferences, and asked to select a preferred answer from a number of alternatives by means of an electronic key-pad. RESULTS: Three quarters of the audience treated their pre-dialysis patients with erythropoietin. However, approximately 50% treated /=75%. In addition, more than half of the respondents said that very few of their patients currently self-administer erythropoietin. Increased healthcare expenditure was the main reason given for limiting treatment. CONCLUSIONS: The survey highlighted important gaps in long-term treatment strategies for pre-dialysis patients. It indicated that new approaches to the treatment of renal anaemia are needed to minimise disease progression and to prevent cardiac dysfunction and associated mortality. Erythropoietin has already been shown to significantly improve the survival of dialysis patients with renal anaemia, and new strategies might, therefore, include the prevention of anaemia in pre-dialysis patients by earlier initiation of erythropoietin therapy.