Introduction:Awareness of the implementation of guideline-directed nephroprotective therapy is an essential preliminary step to optimize implementation of nephroprotective strategies in nondialysis chronic kidney disease (CKD) (ND-CKD). However, updated information on this issue is lacking in the setting of nephrology clinics. Methods:In this multicenter prospective study, we collected data from 4523 patients with ND-CKD, either stage 3 to 5 or 1 and 2 with urinary albumin-to-creatinine ratio (ACR) > 30 mg/g, followed up in 30 Italian nephrology clinics. Patients were evaluated at 2 visits with a 6-month interval between May 2024 and May 2025. The aim was to evaluate the current phenotype of patients under tertiary nephrology care and the management of the 2 major modifiable determinants of renal risk, hypertension and ACR, including therapeutic inertia. Results:The cohort was characterized by a severe cardiorenal risk profile: men comprised 65% of the cohort, mean age was 71 ± 14 years, diabetes was present in 40%, cardiovascular disease in 40%, estimated glomerular filtration rate (eGFR) was 34 ± 19 ml/min per 1.73 m2, and ACR was 70 mg/g (interquartile range: 11-350). At the 6-month visit, in patients with and without diabetes, home and office blood pressure (BP) were above target in about 70% of patients, with a high prevalence of sustained (62%) and resistant (23%) hypertension. Among patients with uncontrolled office BP, 33% and 43% of patients with and without diabetes, respectively, were prescribed ≤ 2 BP-lowering drugs. ACR > 30 mg/g persisted in 61% of nondiabetic and 64% of patients with diabetes. Therapeutic inertia for antialbuminuric agents at month 6 was frequent: 85% for renin-angiotensin system (RAS) inhibitors and 90% for gliflozins. Among patients with diabetes, therapeutic inertia was 92% for glucagon-like peptide-1 receptor agonists (GLP1-RAs) and 96% for finerenone. Conclusion:The large majority of patients with ND-CKD currently followed up in Italian renal clinics are characterized by a severe risk profile that is paradoxically associated with remarkable therapeutic inertia for both traditional and innovative guideline-directed nephroprotective therapy.

The progressive rise in global temperature has led to an increase in heat-related illness and has brought heat-stress nephropathy (HSN) to the forefront as an emerging cause of both acute kidney injury (AKI) and chronic kidney disease (CKD). HSN is characterized by tubulo-interstitial damage and linked to disturbances in water and sodium homeostasis. Observational studies indicate that young, otherwise healthy workers exposed to heat are less likely to develop AKI when hypovolaemia due to sweating is corrected with sodium chloride-containing solutions rather than water alone. This narrative review first summarizes the clinical spectrum, epidemiology, pathophysiology, and prevention of HSN in the context of climate change and the broader epidemic of heat-associated CKD described in several tropical and temperate regions. Then, it examines, in a phylogenetic perspective, the evolution of the two main regulatory systems governing body fluid homeostasis: the antidiuretic hormone (ADH)-thirst axis (water balance) and the renin-angiotensin-aldosterone system (RAAS)-salt appetite axis (sodium balance). In aquatic environments, large external osmotic gradients drove early renal adaptations primarily focused on water handling. Approximately 600 million years ago, ADH-like nonapeptides emerged, enabling tight regulation of plasma osmolality. With the transition to terrestrial life, the development of long loops of Henle, a hypertonic renal medulla, and exquisitely sensitive thirst mechanisms allowed mammals to conserve water very efficiently. By contrast, the RAAS system, central to sodium conservation and effective circulating volume, appeared later (around 400 million years ago) and remains slower and less sensitive, with no behavioural drive equivalent to thirst. The mineralocorticoid receptor is present in fish, but its specific ligand aldosterone first appears in terrestrial vertebrates. The net result is a phylogenetically more refined defence of water than of sodium. We propose that this evolutionary asymmetry underlies the particular renal vulnerability observed in HSN, in which inadequate sodium replacement and suboptimal control of volaemia may predispose to ischaemic tubular injury. Understanding these evolutionary roots may help explaining why, in the era of global warming, the prevention of HSN requires not only water but also appropriate salt replacement and targeted protection of vulnerable populations.

The natural fate of chronic kidney disease (CKD) is the progression to dialysis; however, most patients face fatal and nonfatal cardiovascular events throughout their lifetime. We here address the role of low-density lipoprotein cholesterol (LDL-C) in the excess cardiovascular risk and the impact of traditional and innovative LDL-lowering therapies across the whole spectrum of CKD. Current guidelines on the prevention of atherosclerotic cardiovascular disease (ASCVD) from European and US cardiology societies recommend the assessment of total cardiovascular disease risk to modulate the intensity of preventive strategies in relation to the cardiovascular risk of patients: the higher the cardiovascular risk, the more intense should be the intervention. New drugs have demonstrated efficacy in achieving the lower LDL-C goals not attained by traditional therapy. The detection of vulnerable coronary plaque, rather than merely be the presence of luminal narrowing, provides an attractive imaging target to guide intensified preventive strategies in high-risk population including patients with CKD. In the context of CKD, the patient journey represents a dynamic, longitudinal care pathway in which cardiovascular risk progressively increases in parallel with declining renal function. Despite clear recommendations from nephrology and non-nephrology guidelines, treatment initiation, maintenance and intensification as well as LDL-C target are frequently overlooked in CKD population. Since novel LDL-lowering therapies provide additional therapeutic options for the patients with CKD, it is today mandatory to raise awareness on cardiovascular risk and to integrate lipid management into the broader, longitudinal care of patients with CKD across all stages of disease.

Kidney diseases are among the fastest-growing global health burdens, with chronic kidney disease projected to become the third leading cause of death by 2050. Despite this, therapeutic innovation remains limited: no European Medicines Agency-approved treatment exists for acute kidney injury, and no drugs have demonstrated survival benefits in patients on dialysis. Randomized controlled clinical trials, although pivotal for advancing care, face persistent challenges in nephrology, including patient heterogeneity, multimorbidity, high dropout rates and small populations in rare diseases. In Europe, these intrinsic obstacles are compounded by fragmented implementation of the Clinical Trials Regulation (536/2014), excessive safety reporting demands and lack of nephrology-specific guidance, discouraging academic-led initiatives and limiting pragmatic research. The Coalition for Reducing Bureaucracy in Clinical Trials, a broad alliance of medical societies and patient advocates, has recently published the 'Clinical research in Europe: putting quality and patient safety first' recommendations calling for regulatory harmonization, simplified safety reporting and patient-centred consent. The European Renal Association, a member of the Coalition and contributor to the report, fully supports these recommendations. Implementing such measures is critical to fostering efficient, high-quality nephrology trials in Europe and delivering urgently needed, evidence-based, life-saving and safe therapies for patients with kidney disease.

The year 2025 was crucial for Nephrology: both the World Health Organization (WHO) and the United Nations (UN) formally recognized chronic kidney disease (CKD) as a global health priority among noncommunicable diseases in May and December 2025, respectively. This important milestone is expected to increase worldwide awareness of the urgent need to address the growing burden of CKD. Nephrology is currently undergoing a major paradigm shift: a "back to the future" transition from replacing kidney function through dialysis to preserving kidney function through nephroprotective strategies, which reflects the original mission of the specialty. Nowadays, remission of CKD is increasingly achievable; however, low awareness of CKD among both the general population and non-nephrologists remains a key barrier to optimal kidney disease management. Screening for CKD represents the most effective strategy recommended by international health institutions. The Italian Society of Nephrology (SIN) has therefore developed a screening program to be implemented in Italian primary care offices, combined with educational activities focused on CKD identification and management. The proposal is currently under discussion in the Italian Parliament. On April 15th, 2026, representatives of SIN met members of the European Parliament in Brussels during a closed-door meeting aimed at encouraging the European Parliament and Health Commissions to place CKD firmly on the European health agenda and to promote guidance for Member States supporting the development and implementation of national CKD screening programs in the primary care setting.

In 2025, the World Health Assembly of the World Health Organization (WHO) adopted a resolution on reducing the burden of noncommunicable diseases (NCDs) by promoting kidney health and strengthening the prevention and control of kidney disease. Following the WHO resolution, the United Nations (UN) included kidney health in its 2025 Political Declaration on NCDs. These measures are a clear response to the growing burden of kidney diseases. This achievement for kidney health was facilitated by years of effort by multiple stakeholders and decision-makers, including nephrology associations, particularly the International Society of Nephrology, the European Renal Association (ERA) and the American Society of Nephrology, gathering evidence on the growing burden of chronic kidney disease (CKD), raising awareness of this burden, advancing research and innovation, and adopting scientific and policy recommendations for the early detection, prevention and treatment of CKD. The WHO and UN measures add kidney disease to a list of major NCDs (e.g. cancer, cardiovascular diseases, diabetes, respiratory diseases) that should be prioritized by healthcare systems. The kidney health resolution is fully aligned with the ERA's activities and recommendations, as well as with the 2025 KDIGO document on the prevention of CKD and maintenance of kidney health. This novel preventive approach has been tried and tested for other conditions, such as cardiovascular disease, the age-adjusted mortality of which is falling dramatically, compared with the equally dramatic increase in CKD mortality. The next step would be to define an actionable condition of very high risk of CKD, that may be termed pre-CKD. This should be complemented by programs for the early diagnosis and treatment of CKD, such as the one promoted by ERA's 'Protect Your Kidneys, Protect Your Future' campaign which emphasizes the need to know and treat the ABCDE numbers (Albuminuria, Blood pressure, Cholesterol, Diabetes, Estimated glomerular filtration rate) to improve cardiovascular-kidney-metabolic health.

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.

Background: Commencing peritoneal dialysis (PD) with a lower dose (incremental PD) is a common strategy to improve patient acceptance and reduce treatment burden. However, specific dietary protein recommendations for incremental PD are lacking. Methods: An interim analysis of the I-COPE PD study cohort aimed to assess one-year changes in serum albumin, body mass index (BMI), and metabolic parameters in a cohort of patients on incremental PD. Following local protocols, patients were categorized into two groups according to protein diet prescription: protein diet (PrD) ≤ 0.6 and PrD > 0.6 g/kg/day. Longitudinal changes at baseline, 6 and 12 months were analyzed using mixed-effects models adjusted for age, sex, diabetes, residual kidney function and serum albumin at baseline. Results: We included 205 patients (mean age 63.3 ± 14.2 years; 66% male; 30% diabetes; 92.2% CAPD) and in 45.4% a PrD ≤ 0.6 g/kg/day was prescribed. Baseline demographic, clinical, lab and therapeutic characteristics were well-balanced between the two diet groups. After one year of follow-up, the prevalence of patients persisting in incremental PD was not different between the two dietary groups (59.1% in PrD ≤ 0.6 vs. 63.3% in PrD > 0.6, log-rank test = 0.759), and both groups showed a similar trend in serum albumin, characterized by an initial decline followed by stabilization (p = 0.647), with no significant differences in BMI (p = 0.461). Despite comparable dialysis adequacy, patients on PrD ≤ 0.6 exhibited significantly lower serum urea, phosphate, and potassium levels over time compared to the PrD > 0.6 group. Conclusions: In patients starting incremental PD, the prescription of a lower protein diet could be associated with better control of uremic toxins, while serum albumin levels over time remain comparable to those observed in patients under a higher-protein diet.

OBJECTIVES:Identification of nondialysis chronic kidney disease (CKD) patients at a higher risk of end-stage kidney disease (ESKD) or adverse cardiovascular events is the first essential step to optimize management. We evaluated the role of left ventricular ejection fraction (LVEF) in predicting cardiac and renal outcome in CKD. METHODS:We prospectively studied 580 consecutive patients with nondialysis CKD followed in two Italian renal clinics in order to evaluate the association between LVEF as either continuous variable or categories (>60, 50-60 and <50%) and adjusted risks (hazard ratio, 95% confidence interval) of either cardiovascular (composite of fatal and nonfatal cardiovascular events) or renal events (composite of ESKD and all-cause death before ESKD). RESULTS:The mean age of participants was 65.0 ± 13.5 years, 62% men, eGFR 41.3 ± 21.1 ml/min/1.73 m 2 , LVEF 60.6 ± 8.1% and left ventricular mass index (LVMI) 59.3 ± 17.6 g/m 2.7 . LVEF more than 60%, 50-60% and <50% was recorded in 274, 234 and 72 patients, respectively. Patients with LVEF less than 50% were predominantly men with more frequent history of cardiovascular disease and lower eGFR; in addition, they had higher 24 h, daytime and nighttime blood pressure. During the follow-up (median 5.0 years, IQR 4.9-7.1), cardiovascular and renal endpoints were registered in 113 and 228 patients, respectively. LVEF as a continuous variable was inversely associated with the adjusted risk of either cardiovascular (0.97, 0.95-0.99) or renal endpoint (0.98, 0.97-0.995). In comparison with patients with LVEF more than 60%, the risk of cardiovascular events was increased in patients with LVEF 50-60% (1.64, 1.06-2.53) and less than 50% (2.17, 1.27-3.72). The same occurred for renal endpoint (1.68, 1.24-2.27 and 1.73, 1.15-2.59 for LVEF 50-60% and <50%, respectively). CONCLUSION:In CKD patients, lower LVEF is associated with worse cardiorenal prognosis, independently from LVMI.

Anemia and iron deficiency (ID) are common and significant complications in kidney transplant recipients (KTRs) that can affect their health-related quality of life (HRQoL) and outcomes. Current anemia guidelines equate the post-transplant situation with the anemia associated with chronic kidney disease (CKD) in non-transplanted persons, not acknowledging relevant differences ranging from pathophysiology to clinical manifestation. Nephrologists caring for these patients tend to pay less attention to post-transplant anemia (PTA) and ID than in non-transplanted persons with CKD. In this narrative review we summarize the available evidence about PTA and ID and their specifics in KTRs, including associations with patient and graft survival and poorer HRQoL. The prevalence of anemia is higher in KTRs than in non-transplanted patients with CKD for a given level of glomerular filtration rate (GFR) due to kidney transplant (KT)-specific pathophysiological factors. ID should be detected and corrected in KTRs using oral or intravenous (IV) iron. Some IV iron formulations are associated with an increased risk of hypophosphatemia a typical complication in KTRs. Current guidelines suggest the same hemoglobin targets for erythropoiesis stimulating agent therapy in transplanted and non-transplanted patients, despite the fact that a higher hemoglobin target has been associated with a slower estimated GFR decline in KT. There are insufficient data to recommend the widespread use of hypoxia-inducible factor-prolyl-hydroxylase inhibitors in PTA. Red blood cell transfusions should be avoided to minimize alosensitization. We call for increased awareness and targeted trials on anemia and ID in KTRs, accounting for the diverse and specific profiles of these patients.

Kidney transplant is the therapeutic option of choice in patients with kidney failure. Currently, the number of kidney transplants performed per year is constantly growing in Italy. However, the risk stratification of transplant patients remains an important research question because renal prognosis (risk of graft failure, GF) is still suboptimal, particularly in those who have been transplanted for many years. Furthermore, while the prognostic role of immunological risk factors is well defined, that of the traditional risk factors of chronic kidney disease (CKD) i.e. anemia, hypertension, proteinuria, mineral-bone disease, hyperkalemia, previous cardiovascular event (CVD) and smoking is still little studied. We designed an observational cohort study, enrolling patients undergoing kidney transplant, followed in 6 Nephrology Centers in Italy. The baseline visit of the patients was collected 12 (±2) months after the intervention, i.e. after achieving a stable clinical and biohumoral picture. Demographic and clinical information was collected at the baseline visit. Follow-up continued until the onset of GF. The risk categories were created according to the KDIGO-2024 guidelines. GF incidence rates were calculated by the Poisson method. The adjusted risk of GF was calculated by Cox regression. Overall we studied 757 transplant patients, with an average age of 45.9 ± 11.3 years and 66.5% male. Stage distribution was: 54.5% G1-2, 21% G3a, 18.6% G3b, 5.8% G4. The incidence rate of GF, in a mean follow-up of 6.4 ± 3.6 years, was significantly higher in the presence of anemia (risk ratio, rr 1.9, P = 0.0002), hypertension (rr 1.8 P = 0.0018), proteinuria (rr 1.7, P = 0.006), hyperphosphatemia (rr 2.0 P = 0.048), smoking (rr 2.0, P = 0.034). Cox multivariate analysis showed that, proteinuria (HR 1.42, 95% CI 1.14–1.78), anemia (HR 1.46, 95% CI 1.0–2.12), CVD (HR 1.66 95% CI 1.10–2.50) and smoking (HR 2.26, 95% CI 1.16–4.41) were significantly associated with GF. Risk factors for CKD progression also play a significant role in kidney transplant patients. Such evidence is essential for the management of the transplanted patient during nephrological follow-up.

BACKGROUND:Achieving optimal glycemic control is a cornerstone of cardiovascular risk reduction in type 2 diabetes (T2D). However, the extent to which multifactorial interventions influence this relationship remains uncertain. AIM:To evaluate the association between glycated hemoglobin (HbA1c) target achievement and long-term cardiovascular outcomes in patients receiving standard of care (SoC) or multifactorial intensive therapy (MT). METHODS:This post-hoc analysis of the nephropathy in diabetes type 2 cluster-randomized trial included 323 patients with T2D, albuminuria, and retinopathy (SoC: n = 139; MT: n = 184), who underwent a 4-year intervention phase. Outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. Associations with HbA1c target achievement (≤ 7% vs > 7%) were assessed using Kaplan-Meier curves and shared frailty Cox regression models. RESULTS:During a median follow-up of 12.1 years, 190 MACEs and 139 deaths occurred. Achievement of the HbA1c target was not associated with reduced mortality in either group. However, a significant reduction in MACEs was observed only among SoC patients achieving HbA1c ≤ 7% (P = 0.031), whereas no benefit was seen in the MT group (P = 0.645). In multivariable Cox regression models adjusted for cluster effect, in the MT group age [hazard ratio (HR) = 1.07, P < 0.001] and female sex (HR = 0.38, P < 0.001) were independent predictors of MACE, while in the SoC group only age (HR = 1.04, P = 0.009). For all-cause mortality, age (HR = 1.11, P < 0.001) and blood pressure control (HR = 0.55, P = 0.041) were significant predictors in the MT group, whereas age (HR = 1.06, P = 0.002) was independently associated with increased mortality in the SoC group. CONCLUSION:In high-risk patients with T2D receiving standard care, achieving an HbA1c ≤ 7% was associated with fewer cardiovascular events only under standard care, but not with reduced mortality. This association was not observed in patients managed with a multifactorial strategy. These findings suggest that the prognostic value of glycemic control depends on the broader treatment context and highlight the central role of comprehensive risk factor management in microvascular-complicated T2D.

Asymptomatic bacteriuria (ASB) is a very frequent condition in kidney transplant recipients (KTRs). Guidelines advise against screening and treatment of ASB beyond the first month after renal transplantation. Here, we report the case of a 40-year-old female KTR with untreated ASB complicated with allograft pyelonephritis with urosepsis and acute kidney injury. The reported case highlights that ASB remains a grey area in the management of KTRs (after the first month), and there is a need for new ad hoc studies to identify which patients should be screened and eventually treated. Until new findings are available, it is suggested not to treat KTRs with ASB; however, if ASB is detected, stricter monitoring and non-antibiotic prophylaxis are necessary to favor prevention or prompt therapy of severe urinary tract infections.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce the risk of end-stage kidney disease (ESKD), cardiovascular events, and all-cause mortality in chronic kidney disease (CKD), regardless of diabetes or baseline renal function. However, patients with severely impaired kidney function or on dialysis have been excluded from landmark randomized clinical trials (RCTs). Several off-target mechanisms of SGLT2i could be involved in the cardiac protection of patients with ESKD in which the reduced nephron mass strongly diminishes the tubular effects of SGLT2i. However, available evidence in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) is limited thus leaving efficacy and safety in this population uncertain. Pharmacokinetic studies confirm that dapagliflozin is not dialyzable and shows no significant accumulation in dialysis patients. Small exploratory trials reported favorable cardiovascular and electrophysiological effects of SGLT2i in HD, while retrospective studies suggest they may preserve residual kidney function in incremental dialysis and improve volume status without major safety concerns. Large retrospective cohort analyses of patients starting dialysis showed lower risks of cardiovascular events and mortality in SGLT2i users compared with non-users. When treated with PD, no study has reported outcome data, and findings on efficacy were mixed with some studies showing increased ultrafiltration and lower blood pressure, while others showed no effect on peritoneal glucose transport. The theoretic protection against cardiovascular and mortality risk of SGLT2i must be confirmed by ongoing large-scale trials that will clarify the role of this class of drugs in dialysis populations.

The management of CKD in older patients presents a significant challenge in modern medicine. As the global population ages, the prevalence of CKD among older adults is increasing, which demands effective and safe treatment strategies. The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists has revolutionized the treatment of CKD, offering potential benefits beyond traditional therapies. However, their use in the older population raises essential questions about safety and efficacy, given the unique physiological changes and comorbidities associated with aging. In this CKJ controversy paper, Roberto Minutolo (PRO) and Sophie Liabeuf (CON) debate on the use of SGLT2 inhibitors and GLP-1 receptor agonists in older patients with CKD. Roberto Minutolo advocates the benefits of these medications, highlighting their role in improving cardiovascular outcomes and slowing CKD progression in older patients. He emphasizes the importance of personalized treatment plans based on the patient's cardio-renal risk profile and preferences. In contrast, Sophie Liabeuf expresses concerns about the safety of these drugs in older adults, citing risks such as fractures, acute kidney injury, and urinary tract infections. She argues that treatment decisions should be guided by patient frailty rather than chronological age, as frail individuals are more vulnerable to adverse drug effects. Both contenders agree on the need for more inclusive clinical trials to better understand the impact of these treatments on older populations. While Roberto Minutolo and Sophie Liabeuf present differing perspectives on the use of SGLT2 inhibitors and GLP-1 receptor agonists in older patients with CKD, their views can be seen as complementary rather than strictly opposing. Minutolo's focus on the benefits of these drugs underscores their potential to improve outcomes. Liabeuf's emphasis on caution and the consideration of frailty highlights the need for careful patient assessment. Both agree on the importance of personalized treatment and the inclusion of older patients in future clinical trials, suggesting a shared goal of optimizing care for this vulnerable population. Their debate underscores the complexity of treatment decisions and the necessity of balancing risks and benefits in managing CKD in older adults.

BACKGROUND:The costs of dialysis are not sustainable everywhere, resulting in many avoidable deaths. Interventions that postpone the start of dialysis can save money and lives. This study evaluates the costs associated with protein-restricted diets (PRD) in chronic kidney disease (CKD). METHODS:CKD/4-5 patients adhering to PRD [0.3 g/kg/day, supplemented very-low protein diet (sVLPD); 0.6 g/kg/day, low protein diet (LPD)] and controls on free diet were followed for 5 years, assessing direct and indirect costs. Theoretical and observed analyses compared the estimated and actual costs. RESULTS:A total of 223 subjects under PRD and 1248 controls (CON) were studied; 62 PRD adhering to the diet and 123 propensity-matched CON entered the analyses. In PRD and CON, median survival to end-stage kidney disease (ESKD) was 48.6 [95% confidence interval (CI) 33.8-72] and 28.8 (95% CI 25-41.7) months (P = .017), and median survival to death was 107 (95% CI 96.2-114.5) and 86.6 (95% CI 66.3-103.8) months (P = .004). The monthly costs per patient were 383 euros (€) for CON, 507 € for LPD (+32%) and 767 € for sVLPD (+100%); dialysis monthly costs were 4.150 € (+980%, +720%, +440% vs CON, LPD, sVLPD). By the theoretical model, the individual costs of PRD vs CON were higher in the short follow-up (8255 vs 4595 €/year, +80%), but lower in the long follow-up (8257 vs 23 048 €/year, -64%). At the observed model, which comprises both ESKD and deaths, the costs of PRD were lower either in the short (14 754 vs 21 208 €/year, -30%), or in the long follow-up (21 764 vs 30 089 €/year, -28%). CONCLUSIONS:In patients adherent to diet prescription, PRD delay the start of dialysis, improve survival and save money.

Cardio-kidney metabolic (CKM) syndrome represents a complex and circular interplay of cardiovascular, renal, and metabolic dysfunctions, significantly contributing to global morbidity and mortality. This expert opinion synthesizes insights from a panel of Italian specialists in cardiology, nephrology, and diabetology, advocating for a holistic and integrated framework for CKM management. The recommendations underline the critical need for early identification and stratification of CKM stages, fostering an interdisciplinary approach that bridges specialties and ensures comprehensive care. Emphasizing innovative pathways for collaboration, including dynamic referral protocols, telemedicine, and shared decision-making, the proposed strategies aim to overcome structural and organizational barriers in healthcare. By promoting a unified approach, the framework seeks to streamline CKM care, enhance communication among specialists, and improve the coordination of services. This holistic strategy represents a pivotal step toward mitigating disease progression, improving clinical outcomes, and enhancing the quality of life for patients with CKM syndrome.

Nephrology is the reference of care for patients with overt chronic kidney disease (CKD). Optimization of stratification of the risk of kidney failure (KF) is therefore essential for proper management of CKD in renal clinics. We analyzed data from a prospective observational study involving 3957 non-dialysis-dependent CKD (ND-CKD) patients followed in renal clinics for at least six months. A stepwise selection of predictors was conducted to develop a risk prediction model. Patients who developed KF were younger (61.3 vs. 68 years, P < 0.001), had higher systolic blood pressure (142 vs. 139 mmHg, P = 0.001), higher proteinuria (1.2 vs. 0.3 g/24 h, P < 0.001), lower eGFR (21.3 vs. 35.5 mL/min, P < 0.001), and less frequent use of RAAS inhibitors (68.2% vs. 73.3%, P = 0.003). The 3-year KF risk prediction model included 10 key variables: age, gender, systolic blood pressure, eGFR, 24-hour urine protein, hemoglobin, serum calcium and phosphate, cardiovascular disease (CVD), and RAAS inhibitor use at baseline. The model demonstrated good discrimination, with a C-index of 0.85 (95% CI 0.83–0.87). We have developed a 3-year risk prediction tool for kidney failure in G3a-G4 stage CKD patients under stable nephrology care. This tool may aid in patient communication and support multidisciplinary decision-making in nephrology.