Giornale di Tecniche Nefrologiche & Dialitiche, Apr 1, 2011
La valutazione della funzione sistolica del ventricolo sinistro comprende la valutazione della fo... more La valutazione della funzione sistolica del ventricolo sinistro comprende la valutazione della forma, delle dimen
Vascular calcifications are associated with increased cardiovascular morbidity and mortality. The... more Vascular calcifications are associated with increased cardiovascular morbidity and mortality. Their prevalence is higher in patients with chronic kidney disease than in the general population and they are linked not only to classical risk factors such as hypertension, diabetes, dyslipidemia and smoking but also to derangements in mineral metabolism and to chronic inflammation. The development of vascular calcifications is an active phenomenon that is linked to an imbalance between promoting and inhibitory factors. They affect also young patients on dialysis and it is therefore necessary to recognize them at an early stage. The distinction between intima and media calcification can be important for a different therapeutic approach. There are a number of devices for the identification of vascular calcifications, including x-ray imaging, ultrasonography and computerized technologies. The purpose of this paper is to show the advantages and disadvantages of ultrasonography in comparison to other tools for the diagnosis of vascular calcifications.
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia, Aug 3, 2020
The correct management of patients with kidney stones is a crucial issue for nephrologists. In re... more The correct management of patients with kidney stones is a crucial issue for nephrologists. In recent years, the incidence and prevalence rates of nephrolithiasis have maintained a growing trend worldwide, showing a strong correlation with other systemic disease such as diabetes mellitus, hypertension, obesity, metabolic syndrome and chronic kidney disease. International guidelines indicate computed tomography as the first choice for all adult patients with suspected acute symptoms for obstructive nephrolithiasis. Intravenous pyelogram is more useful in the follow-up of patients with relapsing nephrolithiasis and known stone composition, while the high costs and the long image acquisition times limit the routine use of magnetic resonance. Recent innovative tools have improved the accuracy of kidney stone localization and measuring with B-Mode and color Doppler imaging, thereby reducing the gap between ultrasonography and computer tomography. The aim of this review is to report the latest evidence on risk factors and on the pathophysiology of nephrolithiasis, and to compare the utility of the available imaging techniques in the management of patients with kidney stones, focusing on the role of ultrasonography and the present and future strategies to improve its accuracy.
Fabry Disease (FD), a rare and progressive, X-linked lysosomal storage disorder, is caused by mut... more Fabry Disease (FD), a rare and progressive, X-linked lysosomal storage disorder, is caused by mutations in the α-galactosidase A (GLA) gene which leads to enzymatic deficiency of GLA. Misdiagnosed and undiagnosed FD cases are common for the variable FD phenotype, ranging from asymptomatic and/or impairment of single organs, which is typically seen in females and in patients with late-onset mutation, to multiple organ disease, which is frequently found in males with classic GLA mutation. Consequently, for an early diagnosis and an efficient treatment of FD, three different strategies of screening, newborn screening, high-risk screening and familiar screening, have been conducted. However, most of FD screening in the CKD population has been carried out in hemodialysis patients and kidney transplant recipients, for whom the renal damage is already irreversible, so the effectiveness of enzymatic replacement therapy is limited and delayed therapeutic intervention results in worse long-term outcomes. This review investigates the actual strategies of screening initiatives for the identification of FD, examining in detail those performed in CKD patients not on dialysis.
Cardiovascular disease is the main cause of mordibity and mortality in patients with chronic kidn... more Cardiovascular disease is the main cause of mordibity and mortality in patients with chronic kidney disease (CKD) affected by a series of risk factors (hypertension, anemia, left ventricular hypertrophy, cardiac failure and dyslipidemia). The combined presence of these factors raises the cardiovascular risk in CKD patients considerably compared with that of the general population. Nephrologists can play a role in preventing and treating these risk factors and thereby delaying the development of CKD. In preventing CKD, nephrologists who practice ultrasound techniques should have basic know how of echocardiography so that they can screen CKD patients for early referral to a cardiologist. Echocardiography is a noninvasive ultrasound technique that requires adequately trained doctors to perform it. Nephrologists who practice it need to obtain good training and postgraduate certification of competence in echocardiography. These nephrologists should team up with cardiologists rather than replace them, and at the same time be aware that they possess the basic knowledge to manage cardiovascular disease in CKD patients.
The Doctor-Patient relationship is of fundamental importance in the field of care and continues t... more The Doctor-Patient relationship is of fundamental importance in the field of care and continues to undergo profound transformations. In ancient times the doctor was "authoritarian": the patient was considered a passive element, incapable of understanding, knowing and acting for his own health. The doctor then became a "paternalistic" figure and it is only recently that the patient has become a responsible subject who interacts with the doctor in the definition and evaluation of every health intervention. The patient needs to be actively involved and informed, participating in the therapeutic process and in monitoring the positive and negative effects of the treatment. The doctor needs to communicate in a way that is simple and appropriate in order to avoid misunderstandings, which are very common as patients and doctors can often attribute different meanings to certain words. Doctors need to be aware that such a possibility exists and verify that the patient has understood the real meaning of his words. As good communication between doctors and patients is a strategic factor in care, communication courses should be included in any Medical Degree course.
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia, 2020
The term "obstructive uropathy" refers to the complex structural and functional changes... more The term "obstructive uropathy" refers to the complex structural and functional changes following the interruption of normal urinary runoff, which can occur at every level of the urinary tract. Depending on its origin, duration and severity, urinary tract obstructions can be acute or chronic, mono or bilateral, partial or complete. The obstruction can be localized or extended to the entire pielo-caliceal system and/or homolateral urethra. The term "hydronephrosis" indicates the dilation of the pelvis detected through imaging techniques. Among these, ultrasound is considered the gold standard in the diagnosis of obstructive uropathy: it allows to distinguish three degrees of urinary tract dilation, depending on the extent of the dilation itself and the thickness of the parenchyma. Nephrologists are confronted daily with patients who experience kidney failure and must be able to quickly distinguish between chronic and acute and, in the latter case, to discern betwe...
Prevenzione della nefropatia da mezzo di contrasto iodato "La flebo intelligente": una valida str... more Prevenzione della nefropatia da mezzo di contrasto iodato "La flebo intelligente": una valida strategia nella prevenzione della nefropatia da mezzo di contrasto
Conclusions: This is absolutely the fi rst case in literature, since exist only few cases of robo... more Conclusions: This is absolutely the fi rst case in literature, since exist only few cases of robot-assisted laparoscopic excision, laparoscopic resection or laparotomy. The patient recovered well from the operation and was eventually discharged in a stable state. He's no longer suffering from hypertension and he started playing football again. 24-hour ambulatory blood pressure monitoring, after 15 days from discharge, shows satisfying blood pressure values (Figure 3).
Giornale di Tecniche Nefrologiche e Dialitiche, 2012
La presenza di un accesso vascolare ben funzionante è un presupposto fondamentale per una buona e... more La presenza di un accesso vascolare ben funzionante è un presupposto fondamentale per una buona efficienza dialitica (1) ed è correlata a una ridotta morbilità e mortalità nei pazienti in emodialisi. La fistola artero-venosa (FAV) è un'anastomosi sottocutanea confezionata tra l'arteria radiale e la vena cefalica in sede distale, media o prossimale dell'avambraccio non dominante. Dati gli elevati flussi ematici, il minor rischio infettivo e la maggiore sopravvivenza, la FAV con vasi nativi rappresenta l'accesso vascolare di prima scelta (1-3). Nel caso di grave depauperamento del patrimonio vascolare dell'avambraccio, la protesi in politetrafluoroetilene costituisce una valida alternativa (PTFE). Le linee K/DOQI raccomandano un regolare monitoraggio dell'accesso vascolare e considerano l'eco-colorDoppler (ECD) un valido strumento sia nelle fasi precedenti al suo confezionamento sia nel suo follow-up (4). Tecnica di esecuzione dell'esame Per lo studio della FAV si utilizzano sonde lineari ad alta Duplex ultrasounD in the arterio-venous fistula surveillance abstract. Chronic hemodialysis requires an efficient vascular access which is fundamental for a good dialytic efficiency. The native arterio-venous fistula is preferred for its longer sur vival and lower infection rates. In case of patients with inadequate vessels, synthetic grafts may be created. Periodic monitoring of vascular access with duplex ultrasound has been demonstrated to be able to identify early access dysfunction, thus anticipating surgical inter vention and improving its longterm sur vival. Nevertheless, the need for a systematic monitoring of vascular access with ultrasonography is still debated.
s e211 accurate method to determine the risk of having bad BP. This is a effective method for dia... more s e211 accurate method to determine the risk of having bad BP. This is a effective method for diagnosis of bad BP, which can help a physician achieve better accuracy when giving a diagnosis to the patient.
The lack of backfiltration reduces plasma levels of C-reactive protein and interleukin-6. Paired ... more The lack of backfiltration reduces plasma levels of C-reactive protein and interleukin-6. Paired filtration dialysis is the hemodialfitration technique that abolishes backfiltration. By physically separating convection from diffusion, it allows pure ultrafiltrate to be available during the entire session, so the ultrafiltrate can be regenerated and used as infusion fluid. On these premises, we have developed a European, open, randomised, multicentre study aimed at evaluating the effect of hemodiafiltration with on-line endogenous reinfusion (on-line HFR) on anemia. At least 130 chronically uremic hemodialysed (bicarbonate hemodialysis) stable patients with mild anemia (Hb between 9 and 11 g/dL) will be enrolled and normalized for iron stores by concomitantly repleting iron deposits (if ferritin <300 microg/L) and reducing the dose of erythropoietin to maintain Hb values within the range at enrollment (9-11 g/dL). Patients will be included in the study, randomized to the two treat...
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia
Central venous catheters (CVC) are widely used in clinical practice for the administration of che... more Central venous catheters (CVC) are widely used in clinical practice for the administration of chemotherapy, parental nutrition, hemodynamic monitoring, and hemodialysis. International guidelines have defined the right internal jugular vein as the preferred site of CVC insertion and underline that accurate positioning of the catheter tip is essential to maximize the blood flow and reduce long-term complications. Endocavitary electrocardiography (EC-ECG) improves the accuracy of catheter tip positioning without increasing the placement time by the recognition of typical P wave patterns during catheter insertion:the normally shaped P wave identifies the mid to upper superior vena cava, the widest P wave may be used to place the CVC tip at the superior vena cava-right atrium junction, and biphasic P waves identify the location of the right atrium. Because of its simplicity and safety, EC-ECG should always be considered during CVC placement, especially if other means of verifying correct...
Bone ultrasonography in kidney disease: applications and limitations Quantitative ultrasound (QUS... more Bone ultrasonography in kidney disease: applications and limitations Quantitative ultrasound (QUS) of the bone is a technique that is generating great interest among bone structure researchers because of its intrinsic features. Its safety and low cost make it an ideal technique for repeated measurements over time such as in chronic disease or when it is necessary to monitor the effects of prescribed therapies. The method was developed for the study of osteoporosis and the sites of measurement are all peripheral, including the distal diaphyses and metaphyses of the phalanges, calcaneus, radius and tibia. QUS parameters, however, cannot be used directly for the diagnosis of osteoporosis according to the WHO criteria, although many authors have shown that ultrasound parameters, particularly those of calcaneal QUS, can predict the risk of osteoporotic fractures independently of MBD. Very promising results with the use of QUS have been obtained in corticosteroid-induced osteoporosis, rheumatoid arthritis, Cushing's syndrome, cystic fibrosis, osteomalacia, thalassemia and osteopenia related to parenteral nutrition. QUS can also monitor the effectiveness of therapy in various pathological conditions. In nephrology the combined use of phalangeal QUS and biochemical markers of bone turnover allows adequate follow-up of patients on dialysis and renal transplant recipients with alterations or disorders of the bone.
Giornale di Tecniche Nefrologiche & Dialitiche, Apr 1, 2011
La valutazione della funzione sistolica del ventricolo sinistro comprende la valutazione della fo... more La valutazione della funzione sistolica del ventricolo sinistro comprende la valutazione della forma, delle dimen
Vascular calcifications are associated with increased cardiovascular morbidity and mortality. The... more Vascular calcifications are associated with increased cardiovascular morbidity and mortality. Their prevalence is higher in patients with chronic kidney disease than in the general population and they are linked not only to classical risk factors such as hypertension, diabetes, dyslipidemia and smoking but also to derangements in mineral metabolism and to chronic inflammation. The development of vascular calcifications is an active phenomenon that is linked to an imbalance between promoting and inhibitory factors. They affect also young patients on dialysis and it is therefore necessary to recognize them at an early stage. The distinction between intima and media calcification can be important for a different therapeutic approach. There are a number of devices for the identification of vascular calcifications, including x-ray imaging, ultrasonography and computerized technologies. The purpose of this paper is to show the advantages and disadvantages of ultrasonography in comparison to other tools for the diagnosis of vascular calcifications.
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia, Aug 3, 2020
The correct management of patients with kidney stones is a crucial issue for nephrologists. In re... more The correct management of patients with kidney stones is a crucial issue for nephrologists. In recent years, the incidence and prevalence rates of nephrolithiasis have maintained a growing trend worldwide, showing a strong correlation with other systemic disease such as diabetes mellitus, hypertension, obesity, metabolic syndrome and chronic kidney disease. International guidelines indicate computed tomography as the first choice for all adult patients with suspected acute symptoms for obstructive nephrolithiasis. Intravenous pyelogram is more useful in the follow-up of patients with relapsing nephrolithiasis and known stone composition, while the high costs and the long image acquisition times limit the routine use of magnetic resonance. Recent innovative tools have improved the accuracy of kidney stone localization and measuring with B-Mode and color Doppler imaging, thereby reducing the gap between ultrasonography and computer tomography. The aim of this review is to report the latest evidence on risk factors and on the pathophysiology of nephrolithiasis, and to compare the utility of the available imaging techniques in the management of patients with kidney stones, focusing on the role of ultrasonography and the present and future strategies to improve its accuracy.
Fabry Disease (FD), a rare and progressive, X-linked lysosomal storage disorder, is caused by mut... more Fabry Disease (FD), a rare and progressive, X-linked lysosomal storage disorder, is caused by mutations in the α-galactosidase A (GLA) gene which leads to enzymatic deficiency of GLA. Misdiagnosed and undiagnosed FD cases are common for the variable FD phenotype, ranging from asymptomatic and/or impairment of single organs, which is typically seen in females and in patients with late-onset mutation, to multiple organ disease, which is frequently found in males with classic GLA mutation. Consequently, for an early diagnosis and an efficient treatment of FD, three different strategies of screening, newborn screening, high-risk screening and familiar screening, have been conducted. However, most of FD screening in the CKD population has been carried out in hemodialysis patients and kidney transplant recipients, for whom the renal damage is already irreversible, so the effectiveness of enzymatic replacement therapy is limited and delayed therapeutic intervention results in worse long-term outcomes. This review investigates the actual strategies of screening initiatives for the identification of FD, examining in detail those performed in CKD patients not on dialysis.
Cardiovascular disease is the main cause of mordibity and mortality in patients with chronic kidn... more Cardiovascular disease is the main cause of mordibity and mortality in patients with chronic kidney disease (CKD) affected by a series of risk factors (hypertension, anemia, left ventricular hypertrophy, cardiac failure and dyslipidemia). The combined presence of these factors raises the cardiovascular risk in CKD patients considerably compared with that of the general population. Nephrologists can play a role in preventing and treating these risk factors and thereby delaying the development of CKD. In preventing CKD, nephrologists who practice ultrasound techniques should have basic know how of echocardiography so that they can screen CKD patients for early referral to a cardiologist. Echocardiography is a noninvasive ultrasound technique that requires adequately trained doctors to perform it. Nephrologists who practice it need to obtain good training and postgraduate certification of competence in echocardiography. These nephrologists should team up with cardiologists rather than replace them, and at the same time be aware that they possess the basic knowledge to manage cardiovascular disease in CKD patients.
The Doctor-Patient relationship is of fundamental importance in the field of care and continues t... more The Doctor-Patient relationship is of fundamental importance in the field of care and continues to undergo profound transformations. In ancient times the doctor was "authoritarian": the patient was considered a passive element, incapable of understanding, knowing and acting for his own health. The doctor then became a "paternalistic" figure and it is only recently that the patient has become a responsible subject who interacts with the doctor in the definition and evaluation of every health intervention. The patient needs to be actively involved and informed, participating in the therapeutic process and in monitoring the positive and negative effects of the treatment. The doctor needs to communicate in a way that is simple and appropriate in order to avoid misunderstandings, which are very common as patients and doctors can often attribute different meanings to certain words. Doctors need to be aware that such a possibility exists and verify that the patient has understood the real meaning of his words. As good communication between doctors and patients is a strategic factor in care, communication courses should be included in any Medical Degree course.
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia, 2020
The term "obstructive uropathy" refers to the complex structural and functional changes... more The term "obstructive uropathy" refers to the complex structural and functional changes following the interruption of normal urinary runoff, which can occur at every level of the urinary tract. Depending on its origin, duration and severity, urinary tract obstructions can be acute or chronic, mono or bilateral, partial or complete. The obstruction can be localized or extended to the entire pielo-caliceal system and/or homolateral urethra. The term "hydronephrosis" indicates the dilation of the pelvis detected through imaging techniques. Among these, ultrasound is considered the gold standard in the diagnosis of obstructive uropathy: it allows to distinguish three degrees of urinary tract dilation, depending on the extent of the dilation itself and the thickness of the parenchyma. Nephrologists are confronted daily with patients who experience kidney failure and must be able to quickly distinguish between chronic and acute and, in the latter case, to discern betwe...
Prevenzione della nefropatia da mezzo di contrasto iodato "La flebo intelligente": una valida str... more Prevenzione della nefropatia da mezzo di contrasto iodato "La flebo intelligente": una valida strategia nella prevenzione della nefropatia da mezzo di contrasto
Conclusions: This is absolutely the fi rst case in literature, since exist only few cases of robo... more Conclusions: This is absolutely the fi rst case in literature, since exist only few cases of robot-assisted laparoscopic excision, laparoscopic resection or laparotomy. The patient recovered well from the operation and was eventually discharged in a stable state. He's no longer suffering from hypertension and he started playing football again. 24-hour ambulatory blood pressure monitoring, after 15 days from discharge, shows satisfying blood pressure values (Figure 3).
Giornale di Tecniche Nefrologiche e Dialitiche, 2012
La presenza di un accesso vascolare ben funzionante è un presupposto fondamentale per una buona e... more La presenza di un accesso vascolare ben funzionante è un presupposto fondamentale per una buona efficienza dialitica (1) ed è correlata a una ridotta morbilità e mortalità nei pazienti in emodialisi. La fistola artero-venosa (FAV) è un'anastomosi sottocutanea confezionata tra l'arteria radiale e la vena cefalica in sede distale, media o prossimale dell'avambraccio non dominante. Dati gli elevati flussi ematici, il minor rischio infettivo e la maggiore sopravvivenza, la FAV con vasi nativi rappresenta l'accesso vascolare di prima scelta (1-3). Nel caso di grave depauperamento del patrimonio vascolare dell'avambraccio, la protesi in politetrafluoroetilene costituisce una valida alternativa (PTFE). Le linee K/DOQI raccomandano un regolare monitoraggio dell'accesso vascolare e considerano l'eco-colorDoppler (ECD) un valido strumento sia nelle fasi precedenti al suo confezionamento sia nel suo follow-up (4). Tecnica di esecuzione dell'esame Per lo studio della FAV si utilizzano sonde lineari ad alta Duplex ultrasounD in the arterio-venous fistula surveillance abstract. Chronic hemodialysis requires an efficient vascular access which is fundamental for a good dialytic efficiency. The native arterio-venous fistula is preferred for its longer sur vival and lower infection rates. In case of patients with inadequate vessels, synthetic grafts may be created. Periodic monitoring of vascular access with duplex ultrasound has been demonstrated to be able to identify early access dysfunction, thus anticipating surgical inter vention and improving its longterm sur vival. Nevertheless, the need for a systematic monitoring of vascular access with ultrasonography is still debated.
s e211 accurate method to determine the risk of having bad BP. This is a effective method for dia... more s e211 accurate method to determine the risk of having bad BP. This is a effective method for diagnosis of bad BP, which can help a physician achieve better accuracy when giving a diagnosis to the patient.
The lack of backfiltration reduces plasma levels of C-reactive protein and interleukin-6. Paired ... more The lack of backfiltration reduces plasma levels of C-reactive protein and interleukin-6. Paired filtration dialysis is the hemodialfitration technique that abolishes backfiltration. By physically separating convection from diffusion, it allows pure ultrafiltrate to be available during the entire session, so the ultrafiltrate can be regenerated and used as infusion fluid. On these premises, we have developed a European, open, randomised, multicentre study aimed at evaluating the effect of hemodiafiltration with on-line endogenous reinfusion (on-line HFR) on anemia. At least 130 chronically uremic hemodialysed (bicarbonate hemodialysis) stable patients with mild anemia (Hb between 9 and 11 g/dL) will be enrolled and normalized for iron stores by concomitantly repleting iron deposits (if ferritin <300 microg/L) and reducing the dose of erythropoietin to maintain Hb values within the range at enrollment (9-11 g/dL). Patients will be included in the study, randomized to the two treat...
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia
Central venous catheters (CVC) are widely used in clinical practice for the administration of che... more Central venous catheters (CVC) are widely used in clinical practice for the administration of chemotherapy, parental nutrition, hemodynamic monitoring, and hemodialysis. International guidelines have defined the right internal jugular vein as the preferred site of CVC insertion and underline that accurate positioning of the catheter tip is essential to maximize the blood flow and reduce long-term complications. Endocavitary electrocardiography (EC-ECG) improves the accuracy of catheter tip positioning without increasing the placement time by the recognition of typical P wave patterns during catheter insertion:the normally shaped P wave identifies the mid to upper superior vena cava, the widest P wave may be used to place the CVC tip at the superior vena cava-right atrium junction, and biphasic P waves identify the location of the right atrium. Because of its simplicity and safety, EC-ECG should always be considered during CVC placement, especially if other means of verifying correct...
Bone ultrasonography in kidney disease: applications and limitations Quantitative ultrasound (QUS... more Bone ultrasonography in kidney disease: applications and limitations Quantitative ultrasound (QUS) of the bone is a technique that is generating great interest among bone structure researchers because of its intrinsic features. Its safety and low cost make it an ideal technique for repeated measurements over time such as in chronic disease or when it is necessary to monitor the effects of prescribed therapies. The method was developed for the study of osteoporosis and the sites of measurement are all peripheral, including the distal diaphyses and metaphyses of the phalanges, calcaneus, radius and tibia. QUS parameters, however, cannot be used directly for the diagnosis of osteoporosis according to the WHO criteria, although many authors have shown that ultrasound parameters, particularly those of calcaneal QUS, can predict the risk of osteoporotic fractures independently of MBD. Very promising results with the use of QUS have been obtained in corticosteroid-induced osteoporosis, rheumatoid arthritis, Cushing's syndrome, cystic fibrosis, osteomalacia, thalassemia and osteopenia related to parenteral nutrition. QUS can also monitor the effectiveness of therapy in various pathological conditions. In nephrology the combined use of phalangeal QUS and biochemical markers of bone turnover allows adequate follow-up of patients on dialysis and renal transplant recipients with alterations or disorders of the bone.
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