Publications by authors named "Antonio De Pascalis"

32 Publications

A Preliminary Case-Control Study: Peritoneal Approach in Congestive Heart Failure Treatment.

Blood Purif 2021 Nov 2:1-7. Epub 2021 Nov 2.

Department of Nephrology and Dialysis, Vito Fazzi Hospital, Lecce, Italy.

Background: Congestive heart failure (CHF) associated with worsening renal function is a very common disorder, and, as well known, the goal of the treatment is reducing venous congestion and maintaining a targeted extracellular volume. The objective of the study is to evaluate regular peritoneal ultrafiltration treatment compared to a standard conservative approach in NYHA III-IV CHF patients. In particular, the primary endpoints of the study were the major event-free survival and the total days of medical care per month (which consist of the days of hospitalization and the number of outpatient visits).

Material And Methods: This is a retrospective case-control study. Twenty-four patients were included in the present study. Twelve consecutive patients were treated with peritoneal treatment (group A) and 12 matched for age, gender, and severity of disease with a standard approach. Patients were observed over a maximum period of 18 months. Information on events, hospitalizations, and number of visits was collected during follow-up.

Results: During the follow-up, we observed a major event in 4 patients in group A (33.3%) and in 8 patients in group B (66.7%). In group B, we observed 7 deaths and 1 ICD shock, while in group A, 3 deaths and 1 ICD shock. The number of visits per month was significantly lower in patients treated with the peritoneal method (1.2 [0.4-4.1] vs. 2.5 [2.0-3.1]; p = 0.03). The total days of medical care was significantly lower in group A (2.0 [1.1-5.5] vs. 4.4 [3.0-8.7]; p = 0.034). A multiple event analysis according to the Andersen-Gill model showed a significant event-free survival for group A. During the follow-up, we did not observe any episode of peritonitis in the treated group.

Conclusions: Our study shows that the peritoneal technique is a good therapeutic tool in well-selected patients with CHF. In accordance with prior experience, this intervention has not only an important and significant clinical impact but also potential economic and social consequences.
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http://dx.doi.org/10.1159/000518347DOI Listing
November 2021

The intraoperative intravascular lithotripsy to recruit a calcified radial artery for creating a distal radio-cephalic fistula.

J Vasc Access 2021 Jul 2:11297298211017029. Epub 2021 Jul 2.

Nephrology Unit, Vito Fazzi Hospital, Lecce, Apulia, Italy.

Guidelines for vascular access recommend that the distal autogenous arteriovenous fistula (AVF) should be the first choice-access procedure for patients starting dialysis. Arteriosclerosis of radial artery may cause early failure, as well as failure of maturation of distal arteriovenous fistulas. To increase the incidence of distal AVFs, our team, specialized in vascular access surgery from 2004 onwards, has introduced Intraoperative Transluminal Angioplasty (ITA) under ultrasound (UG) or fluoroscopic guidance, to recruit inadequate arterials for creating distal fistulas. Intravascular lithotripsy (IL) is a novel approach to treat luminal and medial calcifications in patients with peripheral arterial disease and coronary disease. We believe that intraoperative IL may be an opportunity to recruit calcified radial arteries for creating distal radio-cephalic fistulas. Purpose of this study is to describe the intraoperative IL technical applied in our clinical experience. A 37-year-old diabetic patient with distal radio-cephalic fistula was recruited for the first IL experience. One year ago, a wrist radio-cephalic fistula was created in the right upper limb, with intraoperative UG radial artery angioplasty for extensive calcifications. The fistula was functioning but showed a delay in maturation. An angioplasty was unsuccessfully attempted to facilitate the maturation. Subsequently, a surgical revision of the fistula was performed, creating a new anastomosis immediately upstream of the previous one by performing an intraoperative IL UG of the radial artery. The fistula was immediately well functioning, and was cannulated with two needles after 1 month. It is currently being used with intradialytic adequate blood flow. The positive outcome of the case described in this paper, even if only anecdotal, could act as a trigger for further experiences with IL.
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http://dx.doi.org/10.1177/11297298211017029DOI Listing
July 2021

[Nutritional therapy in chronic proteinuric nephropathy].

G Ital Nefrol 2021 Jun 24;38(3). Epub 2021 Jun 24.

UOC Nefrologia e Dialisi, Ospedale Vito Fazzi, Lecce, Italy.

Proteinuria is a well-known marker of renal damage and, at the same time, an important factor in the progression of chronic kidney disease itself. The scientific community has always sought to investigate and provide answers on how nutritional therapy can influence and modify proteinuria and therefore limit its impact on progression to end-stage renal disease. However, despite the importance of the topic, the studies rarely take the form of randomized and controlled trials; in any case, they are often limited to protein intake only, conducted on very heterogeneous populations and, finally, they rarely indicate the precise values of proteinuria. The aim of this work is to explore the different nutritional approaches and their implications in the pathological conditions associated with proteinuria.
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June 2021

The Pre-dilatation of vessels: A simple method to recruit small caliber veins for creating distal fistulas.

J Vasc Access 2021 Jan 22:1129729820983170. Epub 2021 Jan 22.

Nephrology, Dialysis, Transplantation Unit, Vito Fazzi Hospital, Lecce, Italy.

Maturation failure remains a major clinical problem of distal arteriovenous fistula (AVF). Early failure (EF) is associated with the small size of the veins. For about 10 years we have used in more than 1000 fistulas, the Vessels Pre-Dilatation (VPD) to increase the recruitment of small veins for creating distal AVFs. The purpose of this study is to highlight if the VPD can reduce the incidence of EF or failure to mature (FTM) in AVFs created with small veins. Data of all the consecutive patients directly admitted to our Department for their first distal AVF from January to December 2019 were collected. The patients were divided in two groups, one with a vein diameter after the tourniquet ⩽2.0 mm (G1) and one >2 mm (G2). Both in G1 then in G2 the vessels had undergone VPD. Immediate failure (IF), EF, FTM, delayed or arrested maturation rate (DAM), unassisted AVFs and matured AFVs were evaluated. The patients recruited totalled 104, 37 in G1, and 67 in G2. The two groups were homogeneous in age, incidence of diabetes, obesity, heart disease, peripheral vasculopathy, and race. Female were more numerous in G1 (51% vs 12%,  < 0.001). In G1 and G2 occurred respectively 3 IF versus zero ( < 0.05), 10 EF (29%) versus 6 (9%) ( < 0.05), 6 DAM (16%) versus 6 (9%), 21 unassisted AVFs (57%) versus 57 (85%) ( < 0.01). Dividing the patients into groups of unassisted and assisted AVFs, female and low vein diameter are more represented in the assisted group. There were 32 matured AVFs (86%) in G1 and 65 (97%) in G2. In order to increase the incidence of the distal AVF, the PDV allows to include small veins. However, more patients require further interventions to achieve maturation of the fistula.
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http://dx.doi.org/10.1177/1129729820983170DOI Listing
January 2021

How to create and preserve distal fistulas in a large number of patients: the experience of a single centre.

G Ital Nefrol 2020 Dec 7;37(6). Epub 2020 Dec 7.

Nephrology Unit Vito Fazzi Hospital, Lecce. Italy.

: Distal arterio-venous fistula (AVF) is considered the gold standard for vascular access in hemodialysis. The aim of this retrospective study is to report our experience on two innovative techniques, Intraoperative Transluminal Angioplasty (ITA) and Vessel Pre-Dilatation (VPD). : We collected data from all the consecutive patients directly admitted to our Department from January 2014 to October 2018 in order to create or repair an AVF. Early Failure (EF), Failure to Mature (FTM), Late Failure (LF), Primary and Secondary patency rate were evaluated. : All patients underwent VPD; of the total 647 AFVs, 128 received an ITA for the presence of suboptimal vessels. 98.3% of AVFs were located on the forearm. EF occurred in 83 cases; in 67 of these a new AVF was successfully created upstream from the previous one. LF occurred in 100 cases; of these, the access was abandoned in 32 cases and we performed a new AVF upstream from the previous one in 68 cases. FTM occurred in 57 cases, 31 of which were treated with Percutaneous Transluminal Angioplasty (PTA) whilst 26 were resolved performing a new anastomosis upstream. Primary and secondary patency at 1, 2, 3 and 4 years were, respectively, 80%, 74%, 68%, 64% and 94%, 91%, 89%, 88%. By dividing patients into an ITA group and a control group, we did not find any difference in primary and secondary patency. : VPD and ITA could be useful to increase the incidence and the prevalence of distal AVF.
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December 2020

SGLT2 inhibitors, sodium and off-target effects: an overview.

J Nephrol 2021 06 1;34(3):673-680. Epub 2020 Sep 1.

Nephrology, Dialysis and Renal Transplant Unit, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively new class of antidiabetic drugs that in addition to emerging as an effective antihyperglycemic treatment have been shown to improve, in several trials, both renal and cardiovascular outcomes. In consideration of the renal site of action and the associated osmotic diuresis, a negative sodium balance has been postulated during SGLT2i administration. Actually, sodium and water depletion may contribute to some positive actions of SGLT2i but evidence is far from being conclusive and the real physiologic effects of SGLT2i on sodium remain largely unknown. Indeed, no study has yet investigated how SGLT2i change sodium balance in the long term and especially the pathways through which the natriuretic effect is expressed. Furthermore, several experimental studies have recently identified different pathways, not directly linked to tubular sodium handling, which could contribute to the renal and cardiovascular benefits associated with SGLT2i. This paper will review the evidence of SGLT2i action on sodium transporters, their off-target effects and their potential role on kidney protection.
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http://dx.doi.org/10.1007/s40620-020-00845-7DOI Listing
June 2021

Do SGLT-2 Inhibitors Act Only Through a Functional Tubuloglomerular Feedback Induced by the Increased Outflow of Sodium?

Kidney Med 2020 Jul-Aug;2(4):498. Epub 2020 Jun 30.

Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy.

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http://dx.doi.org/10.1016/j.xkme.2020.03.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406851PMC
June 2020

The Off-Target Effects, Electrolyte and Mineral Disorders of SGLT2i.

Molecules 2020 Jun 15;25(12). Epub 2020 Jun 15.

Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40100 Bologna, Italy.

The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a relatively new class of antidiabetic drugs that, in addition to emerging as an effective hypoglycemic treatment, have been shown to improve, in several trials, both renal and cardiovascular outcomes. In consideration of the renal site of action and the associated osmotic diuresis, a negative sodium balance has been postulated during SGLT2i administration. Although it is presumable that sodium and water depletion may contribute to some positive actions of SGLT2i, evidence is far from being conclusive and the real physiologic effects of SGLT2i on sodium remain largely unknown. Indeed, no study has yet investigated how SGLT2i change sodium balance in the long term and especially the pathways through which the natriuretic effect is expressed. Furthermore, recently, several experimental studies have identified different pathways, not directly linked to tubular sodium handling, which could contribute to the renal and cardiovascular benefits associated with SGLT2i. These compounds may also modulate urinary chloride, potassium, magnesium, phosphate, and calcium excretion. Some changes in electrolyte homeostasis are transient, whereas others may persist, suggesting that the administration of SGLT2i may affect mineral and electrolyte balances in exposed subjects. This paper will review the evidence of SGLT2i action on sodium transporters, their off-target effects and their potential role on kidney protection as well as their influence on electrolytes and mineral homeostasis.
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http://dx.doi.org/10.3390/molecules25122757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355461PMC
June 2020

[Native kidney ultrasound in obstructive uropathy].

G Ital Nefrol 2020 Feb 12;37(1). Epub 2020 Feb 12.

UOC Nefrologia e Dialisi, A.O. "Cannizzaro", Catania. Scuola Nazionale di Ecografia Nefrologica, società Italiana di Ultrasonologia in Medicina e Chirurgia (SIUMB), Catania. Commissione Didattica Iter Formativo in Ecografia Nefrologica Società Italiana di Nefrologia.

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 between issues of nephrological or urological competence. This short review aims at helping them deal with this very common scenario, through the use of ultrasound.
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February 2020

Mineral and Electrolyte Disorders With SGLT2i Therapy.

JBMR Plus 2019 Nov 4;3(11):e10242. Epub 2019 Nov 4.

Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Transplantation Unit, St. Orsola Hospital University of Bologna Bologna Italy.

The newly developed sodium-glucose cotransporter 2 inhibitors (SGLT2is) effectively modulate glucose metabolism in diabetes. Although clinical data suggest that SGLT2is (empagliflozin, dapagliflozin, ertugliflozin, canagliflozin, ipragliflozin) are safe and protect against renal and cardiovascular events, very little attention has been dedicated to the effects of these compounds on different electrolytes. As with other antidiabetic compounds, some effects on water and electrolytes balance have been documented. Although the natriuretic effect and osmotic diuresis are expected with SGLT2is, these compounds may also modulate urinary potassium, magnesium, phosphate, and calcium excretion. Notably, they have had no effect on plasma sodium levels and promoted only small increases in serum potassium and magnesium concentrations in clinical trials. Moreover, SGLT2is may induce an increase in serum phosphate, FGF-23, and PTH; reduce 1,25-dihydroxyvitamin D; and generate normal serum calcium. Some published and preliminary reports, as well as unconfirmed reports have suggested an association with bone fractures. Some homeostasis perturbations are transient, whereas others may persist, suggesting that the administration of SGLT2is may affect electrolyte balances in exposed subjects. Although current evidence supports their safety, additional efforts are needed to elucidate the long-term impact of these compounds on chronic kidney disease, mineral metabolism, and bone health. Indeed, the limited follow-up studies and the heterogeneity of the case-mix of different randomized controlled trials preclude a definitive answer on the impact of these compounds on long-term outcomes such as the risk of bone fracture. Here we review the current understanding of the mechanisms involved in electrolyte handling and the available data on the clinical implications of electrolytes and mineral metabolism perturbations induced by SGLT2i administration. © 2019 The Authors. published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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http://dx.doi.org/10.1002/jbm4.10242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874177PMC
November 2019

[A case of Anderson-Fabry disease: a multidisciplinary approach for diagnosis and follow up].

G Ital Nefrol 2018 Sep;35(5)

Unità Operativa Nefrologia e Dialisi, Ospedale Vito Fazzi, Lecce.

Fabry disease (also known as Anderson-Fabry disease, angiocheratoma corporis diffusum, diffuse angiocheratoma) is a rare tesaurismosis linked to the deficiency of the lysosomal enzyme alpha-galactosidase A, required for the physiological catabolism of glycosphingolipids. The related clinical signs show a multisystemic feature and define a degenerative and disabling pathology, whose approach requires a close multidisciplinary specialist collaboration. Currently, the renewed interest in the disease is aimed at the need to provide an early diagnosis, in order to early begin the enzyme replacement therapy and to slow down or avoid the establishment of irreparable organ damage. For this reason, the diagnostic suspicion becomes crucial and arises from the careful observation and research of the symptoms, together with the anamnesis and the overall clinical evaluation of the patient.
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September 2018

Safety and effectiveness of rivaroxaban and warfarin in moderate-to-advanced CKD: real world data.

J Nephrol 2018 Oct 7;31(5):751-756. Epub 2018 Jun 7.

Department of Nephrology and Dialysis, S. Anna Hospital, ASST Lariana, Como, Italy.

Background: In recent years, novel anticoagulant drugs have been introduced in the clinical armamentarium and have progressively gained momentum. Although their use is increasing among CKD patients, some skepticism about their risk-benefit ratio still persists. We sought to investigate the safety and effectiveness of rivaroxaban in a cohort of moderate-to-advanced CKD patients.

Methods: This observational, retrospective, longitudinal study involved 347 consecutive CKD stage 3b-4 (according to NKF-KDOQI guidelines) patients enrolled from 8 cardiac outpatient clinics between March 2015 and October 2017. All patients received anticoagulation (100 warfarin vs. 247 rivaroxaban) as part of their non-valvular atrial fibrillation management at the attending physician's discretion. Clinical effectiveness (defined as the occurrence of ischemic stroke, venous thromboembolism, or transient ischemic attack) and safety (intracranial hemorrhage, gastrointestinal or other bleeding) were assessed separately.

Results: Over a mean follow-up period of 16 ± 0.3 months, 25 stroke episodes (15 hemorrhagic, and 10 ischemic) occurred in 24 warfarin treated patients vs. none in the rivaroxaban arm. There were 5 vs. 0 episodes of deep venous thrombosis and 8 vs. 2 major episodes of bleeding in the warfarin and rivaroxaban groups, respectively. In contrast, the proportion of minor episodes of bleeding was similar between groups.

Conclusion: Rivaroxaban seems a safe and effective therapeutic option in CKD stage 3b-4 patients. However, future randomized controlled trials are needed to definitively establish the role of rivaroxaban in CKD patients.
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http://dx.doi.org/10.1007/s40620-018-0501-7DOI Listing
October 2018

[An unusual presentation of Amyloidosis AL].

G Ital Nefrol 2018 May;35(3)

Unità Operativa Nefrologia e Dialisi, Ospedale Vito Fazzi, Lecce.

We describe the case of a 74-year-old man admitted to our Nephrology Unit with nephrotic syndrome and mild kidney disease. A complete panel of laboratoristic and instrumental tests did not provide useful information for diagnosis. No specific signs or symptoms suggested the presence of AL amyloidosis. As a matter of fact, diagnosis was reached thanks to the hystopathologic examination of renal tissue and bone marrow, since the associated B-cell lymphoproliferative disorder had not revealed itself through serum and urine electrophoresis and immunofixation. This recent case provides the opportunity to review about the disease and to revaluate the renal biopsy as a first line exam in a clinical context where laboratoristic and instrumental tests offer us poor information.
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May 2018

Bone, inflammation and the bone marrow niche in chronic kidney disease: what do we know?

Nephrol Dial Transplant 2018 12;33(12):2092-2100

Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St Orsola Hospital, University of Bologna, Bologna, Italy.

Recent improvements in our understanding of physiology have altered the way in which bone is perceived: no longer is it considered as simply the repository of divalent ions, but rather as a sophisticated endocrine organ with potential extraskeletal effects. Indeed, a number of pathologic conditions involving bone in different ways can now be reconsidered from a bone-centred perspective. For example, in metabolic bone diseases like osteoporosis (OP) and renal osteodystrophy (ROD), the association with a worse cardiovascular outcome can be tentatively explained by the possible derangements of three recently discovered bone hormones (osteocalcin, fibroblast growth factor 23 and sclerostin) and a bone-specific enzyme (alkaline phosphatase). Further, in recent years the close link between bone and inflammation has been better appreciated and a wide range of chronic inflammatory states (from rheumatoid arthritis to ageing) are being explored to discover the biochemical changes that ultimately lead to bone loss and OP. Also, it has been acknowledged that the concept of the bone-vascular axis may explain, for example, the relationship between bone metabolism and vessel wall diseases like atherosclerosis and arteriosclerosis, with potential involvement of a number of cytokines and metabolic pathways. A very important discovery in bone physiology is the bone marrow (BM) niche, the functional unit where stem cells interact, exchanging signals that impact on their fate as bone-forming cells or immune-competent haematopoietic elements. This new element of bone physiology has been recognized to be dysfunctional in diabetes (so-called diabetic mobilopathy), with possible clinical implications. In our opinion, ROD, the metabolic bone disease of renal patients, will in the future probably be identified as a cause of BM niche dysfunction. An integrated view of bone, which includes the BM niche, now seems necessary in order to understand the complex clinical entity of chronic kidney disease-mineral and bone disorders and its cardiovascular burden. Bone is thus becoming a recurrently considered paradigm for different inter-organ communications that needs to be considered in patients with complex diseases.
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http://dx.doi.org/10.1093/ndt/gfy115DOI Listing
December 2018

Folic Acid and Homocysteine in Chronic Kidney Disease and Cardiovascular Disease Progression: Which Comes First?

Cardiorenal Med 2017 Oct 21;7(4):255-266. Epub 2017 Jun 21.

Nephrology, Dialysis, and Transplantation Unit, Department of Experimental, Diagnostic, and Specialty Medicine (DIMES), St. Orsola Hospital, University of Bologna, Bologna, Italy.

Background: Hyperhomocysteinemia (Hhcy) occurs in about 85% of chronic kidney disease (CKD) patients because of impaired renal metabolism and reduced renal excretion. Folic acid (FA), the synthetic form of vitamin B, is critical in the conversion of homocysteine (Hcy) to methionine. If there is not enough intake of FA, there is not enough conversion, and Hcy levels are raised.

Summary: Hhcy is regarded as an independent predictor of cardiovascular morbidity and mortality in end-stage renal disease. Hhcy exerts its pathogenic action on the main processes involved in the progression of vascular damage. Research has shown Hhcy suggests enhanced risks for inflammation and endothelial injury which lead to cardiovascular disease (CVD), stroke, and CKD. FA has also been shown to improve endothelial function without lowering Hcy, suggesting an alternative explanation for the effect of FA on endothelial function. Recently, the role of FA and Hhcy in CVD and in CKD progression was renewed in some randomized trials.

Key Messages: In the general population and in CKD patients, it remains a topic of discussion whether any beneficial effects of FA therapy are to be referred to its direct effect or to a reduction of Hhcy. While waiting for the results of confirmatory trials, it is reasonable to consider FA with or without methylcobalamin supplementation as appropriate adjunctive therapy in patients with CKD.
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http://dx.doi.org/10.1159/000471813DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662962PMC
October 2017

[Neprilysin inhibition and chronic kidney disease].

G Ital Nefrol 2017 Sep 28;34(5):102-112. Epub 2017 Sep 28.

Dipartimento delle insufficienze d'organo e dei trapianti, Policlinico S.Orsola-Malpighi, Bologna, Italy.

Patients with chronic kidney disease (CKD) have a higher incidence of cardiovascular (acute and chronic) events, which in turn have an increased risk of progression to end-stage renal disease (ESRD) Inhibition of neprilysin, in addition to offering a new therapeutic target in patients with heart failure, could represent a potential improvement strategy in cardiovascular and renal outcome of patients with CKD. Inhibition of neprilysin by inhibiting the breakdown of natriuretic peptides, increases their bioavailability resulting in an increase in diuresis and sodium excretion and, in addition to exerting an inhibition of the renin-angiotensin-aldosterone (RAAS) system. Inhibition of RAAS, in turn, generates a series of counter-regulations that can balance the adverse effects present in CKD and heart failure (HF). The idea of blocking neprilysin is not very recent, but the first drugs used as inhibitors had an inadmissible incidence of angioedema. Among the latest generation molecules that can perform a specific inhibitory action on the neprilysin receptor and, at the same time, on the angiotensin II receptor thanks to the association with valsartan there is the LCZ696 (sacubitril / valsartan). This drug has shown promising benefits both in the treatment arterial hypertension and heart failure. It is hoped that equally positive effects may occur in CKD patients, particularly those with macroproteinuria.
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September 2017

[Hypertension in Chronic Kidney Disease].

G Ital Nefrol 2017 Mar;34(Suppl 69):11-19

President of Fondazione Italiana del Rene, Rome, Italy.

The progression of chronic kidney disease CKD is largely independent of the underlying kidney disorder once renal function has fallen below a critical level. Hypertension is an independent risk factor for disease progression in both adult and pediatric patients with kidney disorders. Optimal blood pressure control (130 /80mm Hg) represents a main goal of conservative therapy in patients with chronic kidney disease CKD but it is rarely achieved in clinical practice. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are more effective than other drugs in slowing progression of proteinuric CKD. Dietary salt restriction (≤100 mEq/die of NaCl) may be useful to correct the extracellular volume expansion. If this intervention fails, hypertension can be treated by thiazide diuretics in patients with mild CKD, whereas loop diuretics at adequate doses are indicated in patients with more advanced CKD.
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March 2017

The treatment of type 2 diabetes mellitus in patients with chronic kidney disease: What to expect from new oral hypoglycemic agents.

Diabetes Metab Syndr 2017 Nov 6;11 Suppl 1:S295-S305. Epub 2017 Mar 6.

Department of Health Sciences, S. Paolo Hospital, University of Milan, Italy.

Worldwide, an estimated 200 million people have chronic kidney disease (CKD), whose most common causes include hypertension, arteriosclerosis, and diabetes. About 40% of patients with diabetes develop CKD and intensive blood glucose control through pharmacological intervention can delay CKD progression. Standard therapies for the treatment of type 2 diabetes mellitus include metformin, sulfonylureas, meglitinides, thiazolidinediones, and insulin. While these drugs have an important role in the management of type 2 diabetes, only the thiazolidinedione pioglitazone can be used across the spectrum of CKD (stages 2-5) and without dose adjustment. Newer therapies, particularly dipeptidyl peptidase-IV inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter-2 inhibitors, are increasingly being used in the treatment of type 2 diabetes; however, a major consideration is whether these newer therapies can also be used safely and effectively across the spectrum of renal impairment.
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http://dx.doi.org/10.1016/j.dsx.2017.03.005DOI Listing
November 2017

[Newer anti - diabetic therapies and chronic kidney disease].

G Ital Nefrol 2017 Jan-Feb;34(1)

Worldwide, an estimated 200 million people have chronic kidney disease (CKD), whose most common causes include hypertension, arteriosclerosis, and diabetes. About 40% of patients with diabetes develop CKD. Intensive blood glucose control through pharmacological intervention can delay CKD progression. Standard therapies for the treatment of type 2 diabetes include metformin, sulfonylureas, meglitinides, thiazolidinediones and insulin. While these drugs have an important role in the management of type 2 diabetes, only the thiazolidinedione pioglitazone can be used across the spectrum of CKD (stages 25) and without dose adjustment. Newer therapies, particularly dipeptidyl peptidase-IV inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors are increasingly being used in the treatment of type 2 diabetes. However, a major consideration is whether these newer therapies can also be used safely and effectively across the spectrum of renal impairment.
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November 2017

[Acute Kidney Injury, Type - 3 cardiorenal syndrome, Biomarkers, Renal Replacement Therapy].

G Ital Nefrol 2016 May-Jun;33(3)

Cardiovascular disease and major cardiovascular events represent main cause of death in both acute and chronic kidney disease patients. Kidney and heart failure are common and frequently co-exist This organ-organ interaction, also called organ cross-talk, leads to well-known definition of cardiorenal syndrome (CRS). Here we will describe cardiovascular involvement in patients with acute kidney injury (AKI). Also known as Type-3 CRS or acute reno-cardiac CRS, it occurs when AKI contributes and/or precipitates development of acute cardiac injury. AKI may directly or indirectly produces an acute cardiac event and it can be associated with volume overload, metabolic acidosis and electrolytes disorders such as hyperkalemia and hypocalcemia, coronary artery disease, left ventricular dysfunction and fibrosis which has been also described in patients with AKI with the consequence of direct negative effects on cardiac performance.
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November 2017

[Troponins and chronic kidney disease].

G Ital Nefrol 2015 Jul-Aug;32(4)

Coronary thrombosis was recognized since 19th century as clinical entity with bad outcomes; only in 1912 it was reported that acute myocardial infarction had to been distinguished from angina pectoris. First diagnostic test was electrocardiogram, while white blood cells count and erythrocytes sedimentation rate were the only available laboratory tests. Late in the 60s and 70s glutammic oxaloacetic and glutamic pyravate transaminase, lactate dehydrogenase and creatine kinase were added to biomarkers pool to provide a diagnosis of myocardial infarction related to myocardial cells injury. Only in 1987 assays for cardiac troponin were developed to assess structural damage of myocardial cells and in 2010 high sensibility troponins first dosage kits became available. It is well known that the population with chronic kidney disease (CKD) is at greater risk for cardiovascular disease and death than the general population. The use and interpretation of high sensitivity cardiac troponin (hs-cTn) assays have been particularly challenging in these patients with the majority having elevated levels at baseline. Aim of this review is to evaluate hs-cTn in patients with CKD for the diagnosis of AMI and for the prognostic significance of elevated levels in CKD patients without AMI.
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December 2016

Enterovesical fistula and acute pyelonephritis in renal transplantation. Role of ultrasound.

Arch Ital Urol Androl 2014 Dec 30;86(4):383-4. Epub 2014 Dec 30.

Nephrology and Dialysis Unit, V Fazzi Hospital, Lecce.

The enterovesical fistula is a communication between the urinary tract and the colon and is a rare complication of various inflammatory and cancer diseases. The most frequent cause is represented by diverticulitis of the sigmoid colon and less frequently from Crohn's disease, tumors of the colon and bladder, trauma, radiation therapy and appendicitis. In this report we describe the occurrence of an enterovesical fistula in a patient with renal allograft from a cadaveric donor, which onsetted with signs of acute pyelonephritis and pneumaturia due to diverticulitis of the sigmoid colon, clinically silent. The ultrasound in the diagnosis of enterovesical fistula, yet with a minor role compared to computed tomography (CT), is fundamental being always the first level examination.
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http://dx.doi.org/10.4081/aiua.2014.4.383DOI Listing
December 2014

[Quality of life and hemodialysis].

G Ital Nefrol 2014 Jul-Aug;31(4)

The periodic study of Quality of Life ( QoL) in chronic uremic patients on hemodialysis, is a tool aimed to adapt the approach to the patient, according to the evolving needs. The study sample consisted of 35 subjects (M 65.7% and 34.2 % F), aged 18-84 years (57+16,3) and with an average dialytic age of 6.5 years (+5.3). The tool used was the Multidimensional Inventory for Patient on Hemodialysis (IPPE) which provides a survey for the patients consisting of 24 items to evaluate their degree of agreement/disagreement on a 4-point Lickert scale (false, partially false, partially true, true). The analysis showed that: with respect to the family relationships, criticality was 12.6 %, about the relationship with their body it was 15,8 %, regarding the need to drink it was 22.2%, about the daily life 20.6% and about the perception of their disease it was 7.9 %. Compared to the Index of Global Psychophysical Distress (IPPE), in the sample considered the 67,6% of the patients did not present any problem, the 32.3 % presented a quite critical discomfort and nobody presented any acute critical discomfort. Statistical analysis showed a significant inverse correlation between the IPPE and dialysis age (r = - 0.473, p = 0.005). Although this is a preliminary result of an in-depth understanding of the underlying processes, it may help to identify the factors that, over time, contribute to the patient adaptation to the dialysis treatment, in order to facilitate this process in people who start hemodialysis.
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June 2016

[Chronic kidney disease and sudden death].

G Ital Nefrol 2014 May-Jun;31(3)

Cardiovascular disease represents the major cause of death in chronic kidney disease patients accounting for about 43% of all mortality causes among hemodialysis patients. Sudden cardiac death (SCD) is one of the most frequent and dangerous clinical syndrome occurring in end stage renal disease (ESRD) patients. Hemodialysis patients present a great number of non traditional risk factors for cardiovascular disease such as left ventricular hypertrophy, coronary artery disease, rapid electrolyte shifts, QT dispersion, sympathetic hyperactivity and hyperphosphatemia. The aim of the following review is to summarize epidemiological aspects and pathophysiological pathways of SCD in CKD patients, defining prevention and treatment guidelines.
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March 2016

[Assessment of right ventricular function in patients with chronic kidney disease stage IV NKF].

G Ital Nefrol 2013 Sep-Oct;30(5)

Cardiovascular diseases are accountable for almost 50% of over-all mortality rates in chronic kidney disease (CKD) patients, especially in those who undergo hemo-dialysis or peritoneal dialysis.Hemodialysis patients present higher rates of pulmonary hypertension (PH), an independent risk factor for cardiovascular mortality among this patient population, due in part to the presence and hemodynamic effects of vascular access (both artero-venous fistula and central venous catheter). Echocardiographic TAPSE (tricuspid annular plane systolic excursion) index represents a helpful tool for investigation of right ventricular function together with PAPs (systolic pulmonary artery pressure) evaluation.The following study protocol, introduced by the Cardionephrology Study Group of the Italian Society of Nephrology, aims to evaluate the incidence of right ventricular dysfunction and PH in CKD patients. This is a multicentric, case- control study which includes two arms, each comprising 200 patients, and which will last 24-36 months.Glomerular filtration rates (GFR) are calculated using the eGFR EPI equation, while echocardiographic evaluation includes atrial and ventricular dimension and area, left ventricular systolic function (ejection fraction), diastolic function, TAPSE index measurement and PAPs evaluation.
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August 2015

[Pathophysiology and diagnosis of cardio-renal syndrome: actual picture and future prospectives].

G Ital Nefrol 2013 Sep-Oct;30(5)

The cardiorenal syndrome (CRS) indicates how close the relationship is between heart and kidney during failure of these organs. At present, the classification of the syndrome includes five types of CRS: types I and II which are strictly related to initial heart failure (both acute and chronic), types III and IV which include initial kidney failure, and type V which includes several systemic diseases. Many pathophysiological pathways have been described illustrating how heart and kidney disease are involved in clinical conditions. The diagnosis of CRS is based on both blood tests and ultrasound imaging. Several biomarkers indicating levels of heart and kidney function have emerged over the last few decades which can be used to predict kidney failure in patients with acute or chronic heart disease. Kidney injury biomarkers have also to be tested, especially those indicating glomerular and tubular damage. Renal ultrasound and trans-thoracic echocardiography can provide further information on heart and kidney failure in patients with cardio-renal syndrome at any stage.
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August 2015

Effect of longacting somatostatin analogue on kidney and cyst growth in autosomal dominant polycystic kidney disease (ALADIN): a randomised, placebo-controlled, multicentre trial.

Lancet 2013 Nov 21;382(9903):1485-95. Epub 2013 Aug 21.

IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases, Aldo e Cele Daccò, Bergamo, Italy.

Background: Autosomal dominant polycystic kidney disease slowly progresses to end-stage renal disease and has no effective therapy. A pilot study suggested that the somatostatin analogue octreotide longacting release (LAR) could be nephroprotective in this context. We aimed to assess the effect of 3 years of octreotide-LAR treatment on kidney and cyst growth and renal function decline in participants with this disorder.

Methods: We did an academic, multicentre, randomised, single-blind, placebo-controlled, parallel-group trial in five hospitals in Italy. Adult (>18 years) patients with estimated glomerular filtration rate (GFR) of 40 mL/min per 1·73 m(2) or higher were randomly assigned (central allocation by phone with a computerised list, 1:1 ratio, stratified by centre, block size four and eight) to 3 year treatment with two 20 mg intramuscular injections of octreotide-LAR (n=40) or 0·9% sodium chloride solution (n=39) every 28 days. Study physicians and nurses were aware of the allocated group; participants and outcome assessors were masked to allocation. The primary endpoint was change in total kidney volume (TKV), measured by MRI, at 1 year and 3 year follow-up. Analyses were by modified intention to treat. This study is registered with ClinicalTrials.gov, NCT00309283.

Findings: Recruitment was between April 27, 2006, and May 12, 2008. 38 patients in the octreotide-LAR group and 37 patients in the placebo group had evaluable MRI scans at 1 year follow-up, at this timepoint, mean TKV increased significantly less in the octreotide-LAR group (46·2 mL, SE 18·2) compared with the placebo group (143·7 mL, 26·0; p=0·032). 35 patients in each group had evaluable MRI scans at 3 year follow-up, at this timepoint, mean TKV increase in the octreotide-LAR group (220·1 mL, 49·1) was numerically smaller than in the placebo group (454·3 mL, 80·8), but the difference was not significant (p=0·25). 37 (92·5%) participants in the octreotide-LAR group and 32 (82·1%) in the placebo group had at least one adverse event (p=0·16). Participants with serious adverse events were similarly distributed in the two treatment groups. However, four cases of cholelithiasis or acute cholecystitis occurred in the octreotide-LAR group and were probably treatment-related.

Interpretation: These findings provide the background for large randomised controlled trials to test the protective effect of somatostatin analogues against renal function loss and progression to end-stage kidney disease.

Funding: Polycystic Kidney Disease Foundation.
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http://dx.doi.org/10.1016/S0140-6736(13)61407-5DOI Listing
November 2013

Acute interstitial nephritis, a rare complication of Giardiasis.

Clin Pract 2012 Jan 30;2(1):e6. Epub 2011 Dec 30.

Nephrology, Dialysis and Renal Transplantation Unit, V. Fazzi Hospital, Lecce, Italy.

Acute interstitial nephritis is a relevant cause of acute renal failure. Drugs are the predominant cause, followed by infections and idiopathic lesions. Acute interstitial nephritis as a form of hypersensitivity reaction is an uncommon manifestation in the setting of human parasitic infections. We present a case of acute interstitial nephritis in association with Giardia infection in a 54-year-old woman who developed an impairment of renal function after a prolonged period of slight fever and diarrhea. After an attempt to recover renal impairment by vigorous rehydratation, because of the unclear origin of the persisting renal failure, a percutaneous renal biopsy was performed and a diagnosis of severe acute interstitial nephritis was made. Steroid therapy was started and after six weeks, renal function had completely recovered. In cases of unexplained renal failure in patients affected by parasitic infections, interstitial nephritis should be considered and it is our opinion that a renal biopsy should be always performed.
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http://dx.doi.org/10.4081/cp.2012.e6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981349PMC
January 2012
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