Background. The spread of home hemodialysis is increasing in Italy and across Europe, as noted in the document ("La diffusione dell'emodialisi domiciliare sta aumentando in Italia ed in Europa"). Its main feature enabling hospital use is its portability and independence from centralized water treatment systems, thanks to the use of sterile pre-mixed dialysate bags. This allows treatments to be delivered in environments not traditionally equipped for dialysis, such as isolation rooms on inpatient wards, emergency departments, or temporary units prior to definitive intrahospital transfer. Materials and Methods. Dialysis therapy used: The NxStage VersiHD system was employed to perform hemodialysis in three clinical scenarios: 1. Non-transportable patient with anasarca and acute kidney injury. The patient, hospitalized in the pulmonology ward and receiving oxygen therapy via tracheostomy, developed acute kidney injury with anuria requiring renal replacement therapy. The NxStage VersiHD device, already available in the dialysis unit, was transported to the patient's room. Two treatments were performed using 25 L of dialysate: the first lasting 3 hours and the second 4 hours. The system was used emergently for ultrafiltration and solute clearance until spontaneous diuresis resumed, despite a logistically challenging setting. 2. Chronic hemodialysis patient presenting to the emergency department with severe dyspnea due to fluid overload and SARS-CoV-2 infection. Because timely isolation in the dialysis unit was not feasible, urgent hemodialysis was performed using the NxStage VersiHD in a day-hospital room of our department, achieving reduction of pulmonary edema. 3. A 61-year-old woman with cirrhosis presented with splenic hemorrhage and acute renal failure. Admitted to intensive care, she underwent CVVHDF for 72 hours. She was transferred to the nephrology ward, which was not transportable due to the risk of hemorrhage. The NxStage VersiHD and the necessary equipment for dialysis scheduled for the following day were transported to the ward. Conclusions. The report aims to highlight the feasibility of using a home-designed dialysis technology safely within specific intrahospital contexts, offering an alternative strategy for dialysis support when infrastructural limitations or patient immobility prevent standard approaches. Staff training on NxStage operation, emergency procedures, and complication management is essential to minimize human error. The main challenges in training hospital nursing teams for occasional NxStage use include limited operational familiarity, management of device-specific complications, and integration of safety protocols. Operational unfamiliarity arises because, although NxStage is designed to simplify setup through preassembled cartridges and sterile dialysate bags, it differs technically from conventional dialysis systems. Lack of routine use is the primary reason for failure of NxStage implementation projects in hospital settings. To address this issue, our center adopted continuous use of NxStage in the dialysis unit for selected patients, ensuring regular machine operation. To avoid inadequate clearance with a thrice weekly schedule, 4 hour sessions were performed in patients with a distribution volume compatible with achieving a weekly Kt/V of 2.2, in accordance with international guidelines.
We report the case of a 64-year-old man referred for evaluation of progressive renal dysfunction associated with hypertriglyceridemia and non-nephrotic proteinuria. There was no evidence of plasma cell dyscrasia, chronic inflammatory disease, or other secondary causes of amyloidosis. Renal biopsy revealed amyloid deposits with predominant glomerular involvement. Congo red staining confirmed the presence of amyloid, showing characteristic apple-green birefringence under polarized light. Immunohistochemical studies were non-diagnostic. Therefore, laser microdissection followed by mass spectrometry-based proteomic analysis was performed and identified apolipoprotein C-II (ApoC-II) as the main component of the amyloid deposits. Genetic analysis subsequently demonstrated a heterozygous c.122A>C (p.Lys41Thr) variant in the APOC2 gene, confirming the diagnosis of hereditary apolipoprotein C-II-related amyloidosis (AApoC-II), a very rare form of hereditary amyloidosis with predominant renal tropism.
Background. Cardiovascular-kidney-metabolic (CKM) syndrome encompasses obesity, type 2 diabetes, cardiovascular disease, and chronic kidney disease. Insulin resistance has traditionally been considered the primary driver, with hyperinsulinemia viewed as a compensatory response. However, emerging evidence suggests that hyperinsulinemia may precede insulin resistance in specific phenotypes and contribute to early disease mechanisms. Methods. We conducted a narrative review of the role of hyperinsulinemia in CKM syndrome. Literature searches were performed in PubMed/MEDLINE, Embase, and Scopus through December 2025. We prioritised prospective cohort studies, meta-analyses, Mendelian randomisation studies, and randomised controlled trials, and synthesised evidence across cardiovascular, renal, and metabolic domains. Results. Sustained hyperinsulinemia is associated with myocardial hypertrophy and fibrosis through selective preservation of mitogenic signalling, contributing to heart failure phenotypes. In the kidney, it enhances sodium and glucose reabsorption, increases intraglomerular pressure, and promotes podocyte dysfunction, potentially accelerating CKD progression. Epidemiological evidence consistently shows associations between elevated fasting insulin levels and cardiovascular events, renal outcomes, and mortality across diverse populations, with meta-analytic estimates reporting a pooled relative risk of 1.46 (95% CI 1.16-1.84) for incident cardiovascular events. However, available data are largely observational and heterogeneous in exposure definitions and adjustment models. Conclusions. Hyperinsulinemia represents a clinically relevant and potentially modifiable component of CKM syndrome, with effects extending beyond glucose homeostasis. While causality is biologically plausible and supported by genetic and epidemiological evidence, it remains to be established through interventional studies. Recognition of hyperinsulinemia may support earlier risk stratification and mechanism-based interventions, although prospective validation is required before routine clinical implementation.
Throughout the natural history of chronic kidney disease (CKD), most patients experience fatal or non-fatal cardiovascular events. In this review, we address the role of low-density lipoprotein cholesterol (LDL-C) in the excess cardiovascular risk associated with CKD and examine the impact of both traditional and novel LDL-C-lowering therapies across the entire spectrum of CKD. Current guidelines for the prevention of atherosclerotic cardiovascular disease (ASCVD), developed by European and US cardiology societies, recommend assessment of overall cardiovascular risk to tailor the intensity of preventive strategies to the individual patient's risk profile: the higher the cardiovascular risk, the more intensive the intervention should be. Novel therapies have demonstrated efficacy in achieving lower LDL-C targets, which are often unattainable with conventional treatment. The identification of vulnerable coronary plaques, rather than the mere presence of vascular lumen narrowing, represents a promising imaging target for guiding intensified preventive strategies in high-risk populations, including patients with CKD. In CKD, cardiovascular risk progressively increases as kidney function declines. Despite clear recommendations from both nephrology and non-nephrology guidelines, initiation, maintenance, and intensification of lipid-lowering treatment, as well as achievement of LDL-C targets, remain suboptimal in the CKD population. As novel lipid-lowering therapies provide additional therapeutic options for patients with CKD, there is now a compelling need to increase awareness of cardiovascular risk and integrate lipid management into the broader, longitudinal care of patients with CKD across all stages of the disease.
Ultrasound is nowadays widely used in nephrological practice as a first-line clinical tool. Despite this widespread adoption of the technique, the medico-legal aspects of ultrasound reporting have so far received limited attention, even though the report represents the formal completion of the medical act and the only document endowed with probative value. In the legal context, in fact, the ultrasound examination can be assessed exclusively through what is documented in the report, regardless of the technical quality of the examination itself. The present paper analyzes the main medico-legal aspects of ultrasound reporting, with particular reference to the activity of the nephrologist, focusing on the essential requirements of the report, the most common critical issues with medico-legal relevance, and the implications in terms of professional liability. The role of declaring the limitations of the examination and of structured reporting as possible tools for clinical risk management and professional protection will also be examined.
Renal rehabilitation is increasingly recognized as a complementary strategy to address the clinical and functional complications of maintenance hemodialysis. This review evaluated the effects of renal rehabilitation, including structured exercise, nutritional support, and multidisciplinary interventions, on anemia, nutritional status, and activities of daily living in adults undergoing maintenance hemodialysis. Studies published between 2015 and 2025 were reviewed according to PRISMA criteria, and 42 studies were included in the qualitative synthesis. Overall, renal rehabilitation was associated with modest improvements in hemoglobin levels and erythropoiesis-stimulating agent responsiveness, as well as favorable changes in nutritional and muscle-related parameters. The most consistent benefits were observed in functional outcomes, including exercise capacity, muscle strength, frailty, and activities of daily living. These findings support renal rehabilitation as a promising multidimensional approach in maintenance hemodialysis, although heterogeneity among interventions and study designs highlights the need for standardized, adequately powered long-term trials.
Background. The aging healthcare workforce in Italy, with an average age approaching 50 years, creates demographic imbalances that hinder intergenerational collaboration and knowledge transfer. This issue is particularly critical in nephrology, where nurses play a pivotal role in delivering personalized care by combining advanced technical expertise with high-quality human support. This study aims to evaluate and compare the generational characteristics of Italian nurses working in the nephrology field. Methods. A cross-sectional study based on the Multidimensional Nursing Generations Questionnaire (MNGQ), administered between February 2023 and February 2024 to nurses working in the nephrology field. Findings. The study involved 520 Italian nurses working in the nephrology field. The analysis revealed significant generational differences. Millennials exhibited the highest levels of intergenerational conflict (p < 0,001) and greater adaptability to change (p < 0,001), while Baby Boomers reported higher scores in patient safety perspectives (p = 0,003). Younger generations (Millennials and Generation X) demonstrated a greater work propensity compared to Baby Boomers (p < 0,001). No significant differences were observed in teamwork (p = 0,199). Conclusion. The study highlights how generational differences impact the nursing profession in Italy, particularly in nephrology, where academic and practical skills coexist. To harmonize these competencies, institutions should promote mentorship programs and collaborative training, fostering inclusive work environments that enhance teamwork and care quality while addressing the evolving challenges of the healthcare system.
Background. Renal biopsy is widely performed worldwide, but reported bleeding risks vary due to differences in technique, devices, operators, and patient populations. This study aimed to define the bleeding risk associated with current spring-loaded biopsy guns in a South-Asian population, identify relevant risk factors, and quantify the additional cost and hospital stay from bleeding complications. Methodology. In this six-month prospective observational cohort study, all adult patients undergoing kidney biopsy at a tertiary hospital were enrolled. Demographic, clinical, radiological, procedural, and histopathological data were collected. Bleeding was defined as gross haematuria, perinephric hematoma, hemoglobin drop, transfusion requirement, or need for intervention. Factors associated with bleeding were evaluated using univariate analysis and multivariate logistic regression. Results. Among 980 patients, overall bleeding incidence was 4.9%, with 1.6% clinically significant events. On univariate analysis, higher creatinine, urea, dialysis dependence, and ischemic heart disease were associated with bleeding, whereas diabetes mellitus was associated with lower bleeding risk. On multivariate analysis, ischemic heart disease remained independently associated with bleeding, while diabetes mellitus remained associated with lower bleeding risk. Histopathological chronicity, including glomerulosclerosis and interstitial fibrosis, was also associated with clinically significant bleeding events (requiring transfusion or intervention). Conclusions. Bleeding after kidney biopsy was infrequent in this cohort. Ischemic heart disease and histopathological chronicity were associated with increased bleeding risk, while procedural and operator-related factors were not significantly associated in this cohort, although these findings should be interpreted cautiously. Bleeding was associated with increased hospital stay and healthcare costs.
Objective. To evaluate the acute cross-shift changes in renal function and occupational risk factors associated with environmental nephropathy among rural workers in the Colombian Caribbean. Material and Method. An observational, cross-sectional analytical study was conducted with a community-based sample of 78 active rural workers (48 agricultural and 30 construction workers). Variables analyzed included sociodemographic characteristics, toxic habits, agrochemical exposure, fluid intake, and clinical parameters. Blood and urine samples were collected pre- and post-shift. A multivariable linear regression model was constructed to identify independent predictors of the acute cross-shift decline in estimated glomerular filtration rate (ΔeGFR). Results. The cohort was highly exposed to adverse occupational conditions, including prolonged workdays (69% worked > 48 hours per week) and insufficient hydration (79% consumed < 3 liters of fluid daily). Post-shift analysis revealed significant acute physiological stress, including a significant decline in overall eGFR (p < 0.001) and acute increases in urinary specific gravity, incident proteinuria (p=0.008), and leukocyturia (p<0.001). Notably, incident hematuria increased significantly across the workday exclusively among agricultural workers (21% to 40%, p = 0.02). Multivariable analysis identified occupational exposure to herbicides (β = -16, p = 0.014) and active smoking status (β = -12, p = 0.016) as the strongest independent predictors of acute cross-shift renal function loss. Conclusion. Workers under adverse environmental conditions in the Colombian Caribbean experience severe acute cross-shift declines in renal function and markers of acute tubular injury, driven by heavy labor, heat stress, and herbicide exposure.
Introduction. In Africa, particularly in Senegal, sarcopenia among patients undergoing hemodialysis remains insufficiently studied. In this context, we conducted this study with the objective of describing the epidemiological and etiological aspects of sarcopenia among hemodialysis patients in Dakar in 2025. Patients and Methods. We carried out a multicenter, cross-sectional, descriptive and analytical study over a 15-day period in four hemodialysis centers in Dakar. Sarcopenia was diagnosed according to the diagnostic criteria of the EWGSOP2 working group. Cluster sampling of hemodialysis centers was performed, followed by stratified sampling by dividing patients into two groups: younger patients (< 65 years) and older patients (≥ 65 years). All patients on chronic hemodialysis for at least three months were included. Results. A total of 152 patients were included. The mean age was 47.88 ± 13.68 years. There were 77 men (50.7%) and 75 women (49.3%), with a sex ratio of 1.02. The mean body mass index (BMI) was 20.72 ± 4.91 kg/m² (range: 12.65-38.39), and 23.7% of patients had a BMI < 18.5 kg/m². The mean serum ferritin level was 829.73 ± 778.4 ng/mL. Based on the SARC-F questionnaire, sarcopenia was suspected in 55 patients. Handgrip strength was reduced in 82 patients (53.94%), including 38 men and 44 women. Bioelectrical impedance analysis confirmed sarcopenia in 64 patients, yielding a prevalence of 42.10%. Thirty patients presented with severe sarcopenia. In multivariate analysis, factors independently associated with sarcopenia were male sex (OR = 5.98; 95% CI: 2.27-15.74), undernutrition (BMI < 18.5) (OR = 6.25; 95% CI: 2.08-18.74), and overweight (BMI > 25) (OR = 0.06; 95% CI: 0.01-0.49). Conclusion. Sarcopenia is common among hemodialysis patients in Dakar. Male sex, and undernutrition are significant risk factors. A prospective cohort study would be relevant to better assess its prevalence, risk factors, and prognostic impact.
Introduction. Physician-patient communication is a pivotal element in the management of chronic kidney disease (CKD), yet it is sometimes reduced to a mere transmission of information. Ineffective communication undermines therapeutic adherence, delays clinical decision-making, and negatively impacts patients' quality of life. Methods. We conducted a panoramic review of the literature, with a specific focus on nephrology context, examining how various aspects (communication barriers, patient expectations, use of multimedia tools, digital self-monitoring) affect clinical outcomes and can transform from critical issues into resources for improving the therapeutic alliance and adherence. Results. Evidence shows that: (1) physician-patient communication, expectations, and genuine understanding directly influence clinical outcomes; (2) digital tools such as educational/storytelling videos, online platforms, institutional social media channels, and dedicated apps improve health literacy and patient engagement; (3) self-monitoring and smart devices can help strengthen awareness and foster the doctor-patient relationship, even remotely; (4) therapeutic adherence can be significantly improved through empathetic and shared care relationships, including through digital media, countering misinformation and mistrust. Conclusions. Innovating communication in nephrology requires moving beyond the traditional information-delivery model, embracing narrative and digital approaches, and recognizing communication as a fully-fledged therapeutic intervention.
Introduction. Pain during arteriovenous fistula (AVF) cannulation remains a major concern among patients undergoing maintenance hemodialysis. This study was done to assess the effectiveness of cryotherapy in reducing patient perceived pain during AVF cannulation. Methods. This randomised crossover study was carried out on 111 hemodialysis patients. During the first four sessions, the patients received cryotherapy intervention and during next four sessions, the patients received standard care without cryotherapy. Pain was assessed using the Wong-baker faces pain rating scale. Results. There was a significant difference between pain scale with intervention and without intervention, with p value of 0.001. Conclusions. In hemodialysis patients, pain was reduced during AVF cannulation when cryotherapy was used.
Acute liver failure (ALF) and acute on chronic liver failure (ACLF) represent severely compromised clinical conditions, characterised by high mortality and often candidates for liver transplantation. Recently, non-biological extracorporeal treatments (ECLSD) have gained an increasing role as temporary support through the removal of water-soluble and albumin-bound toxins. This paper provides an overview of the main available devices, including SPAD (single pass Albumin Dialysis), MARS (Molecular Adsorbent Recirculation System), Prometheus (Fractionated Plasma Separation and Adsorption), Cytosorb, CPFA (Coupled Plasma Filtration Adsorption) and DPMAS (Dual Plasma Molecular Adsorption System), illustrating their technical characteristics, efficacy and limitations. Cytosorb, although originally designed for the treatment of systemic inflammatory conditions, has shown surprising efficacy in reducing bilirubin and bile acids, surpassing the results of MARS in some retrospective studies. Special attention is given to our centre's experience with the RAED (Recirculated Albumin Extended Dialysis) and RHENOB (Reemplazo Hepático No Biológico) techniques, based on recirculated albumin circuits, with or without regeneration by DPMAS. In a series of seven patients with ALF or ACLF treated with RHENOB, a significant reduction in bilirubin (25-50%) was observed after only a few sessions, without haemodynamic adverse events. One patient subsequently received a successful liver transplant, completing the biochemical stabilisation course. The RAED and RHENOB techniques appear to be innovative, effective, cost-effective approaches that can be applied even in centres without advanced technology. However, controlled prospective studies are needed to consolidate their use in clinical practice.
Arteriovenous fistula (AVF) for hemodialysis can lead to various complications in transplanted patients, particularly on an iatrogenic basis and due to hemodynamic changes: aneurysm - whether venous, arterial, or arteriovenous - is one such complication. Shear stress and the activation of oxygen radicals can affect the remodeling of the vessel wall (type IV and V collagen). We describe a case of a rare aneurysm of the anastomotic chamber. In January 2025, a 55-year-old woman with a well-functioning kidney transplant on triple anti-rejection therapy presented to our clinic. She complained of a painful pulsation at the site of the distal left radio-cephalic AVF anastomosis, which had developed over the past two days. An ultrasound-color Doppler examination revealed an aneurysm of the anastomotic chamber involving the radial artery. We recommended evaluation in the emergency department for surgical assessment. The patient underwent aneurysmectomy with reconstruction of the wall continuity and ligation of the AVF a few hours later. Conclusions. Thanks to the color Doppler ultrasound examination, we diagnosed a rare arteriovenous aneurysm of the AVF in a transplanted patient. Monitoring seems necessary in this category of patients for the management of severe complications that may be favored by anti-rejection therapy.
Hemodialysis performed with a low-temperature dialysate (< 36 °C) represents an effective strategy for preventing intradialytic hypotension and, more generally, for improving patient hemodynamics. Additional benefits from this approach may also extend to other systems, such as the cardiovascular and central nervous systems. Despite these undoubtedly favorable effects, some drawbacks have been reported, including significant patient discomfort, while data regarding extracorporeal clearance remain inconsistent. In light of these considerations, and through the analysis of major studies published in PubMed® over the past decade, we aim to provide a comprehensive and critical appraisal referred to as «cool dialysis».
The demographic and epidemiological transition that Italy has undergone over the past 50 years has made palliative care (PC) essential in situations where active treatment is no longer proportionate. One of the major current and future challenges of palliative care lies in the management of non-oncological chronic diseases, particularly advanced organ failure and dementia. Individuals aged over 70 and 80 represent a significant proportion of the more than 45,000 chronic dialysis patients in Italy. These patients typically present with increased comorbidities, reduced life expectancy and quality of life, and a higher risk of hospitalization and in-hospital mortality. Moreover, older adults in these age groups also constitute the majority of the approximately 15% of patients with end-stage renal disease (ESRD) who continue exclusively with conservative management, never initiating renal replacement therapy. Over the past decade, interest in palliative care within the field of nephrology has grown substantially across the Western world. Decisions to withhold or withdraw dialysis vary widely by region, with higher rates observed in North America and Canada, and lower rates in Southern Europe. The Italian Society of Palliative Care (SICP) published with the Italian Society of Nephrology (SIN) and the Italian Society of Nephrology Nurses (SIAN), ten and six years ago respectively, a consensus document on the integration of palliative care in the management of chronic kidney disease. The objective of this study is to provide a comprehensive overview of the current state of palliative care practices within nephrology units across Italy.
Introduction. Chronic kidney disease (CKD) is a major complication in type 2 diabetes (T2D), leading to increased cardiovascular risk. Empagliflozin, a sodium-glucose cotransporter-2 inhibitor (SGLT2i), has shown cardiorenal benefits in clinical trials, but real-world data in patients with moderate CKD are limited. Objectives. To retrospectively evaluate changes in estimated glomerular filtration rate (eGFR) following empagliflozin initiation in T2D patients with CKD (KDIGO 3A and 3B stages), focusing on the occurrence and impact of early eGFR decline ("dip") and associated metabolic outcomes and cardiovascular risk factors. Methods. This multicenter study included adult T2D patients with eGFR 30-60 mL/min/1.73 m² who started empagliflozin between October 2023 and April 2024. Clinical parameters were collected at baseline, 1 month, and 6 months. Subgroup analyses were conducted by CKD stage and eGFR dip status (>10% decline at 1 month). Results. Among 166 patients, 21.6% experienced an eGFR dip. Overall, eGFR increased by 2.75 mL/min/1.73m² at 6 months (p < 0.0001), with more pronounced improvement in non-dippers and CKD 3A patients. In dippers, eGFR partially recovered. HbA1c decreased by ~4 mmol/mol (despite use of concomitant glucose-lowering drugs decreased at empagliflozin initiation), weight by ~2 kg, and systolic blood pressure by ~4 mmHg. Empagliflozin discontinuation occurred in 4.2% of patients, mainly due to genitourinary infections. Discussion. Empagliflozin was associated with stabilization or improvement in renal function and modest metabolic benefits in T2D patients with CKD stage 3. The eGFR dip was infrequent and transient, supporting the continued use of empagliflozin in this population in real-world settings.
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have redefined the therapeutic landscape of heart failure (HF), both with reduced (HFrEF) and preserved (HFpEF) ejection fraction. Historically, treatment has relied on diuretics to relieve congestion, with limited prognostic impact and dose-related adverse effects. SGLT2i, originally developed for type 2 diabetes mellitus, have demonstrated in randomized trials a significant reduction in hospitalizations and cardiovascular mortality, with benefits extending to non-diabetic patients. SGLT2 inhibitorsTheir mechanism combines moderate osmotic natriuresis, selective reduction of extracellular volume, renal protection, and minimal neurohormonal activation. In contrast to loop diuretics, which induce rapid volume depletion and RAAS activation, SGLT2i stabilize sodium-water balance without significant hemodynamic compromise. In clinical practice, their combination with diuretics requires careful titration to prevent hypovolemia, hypotension, and renal dysfunction, especially in frail elderly patients. Evidence suggests that SGLT2i may reduce chronic diuretic requirements, improve renal function, and provide additional cardiovascular protection. These findings support their early and integrated use, positioning SGLT2i as a cornerstone in the contemporary management of heart failure.
