[Cephalic arch stenosis. Case report and literary review].

Dysfunctional AVF represents one of the leading causes of morbidity in the hemodialysis population, with venous stenosis-related dysfunction being the most common underlying problem. Cephalic arch is a well-known site for the development of stenosis, especially in patients with brachiocephalic fistulas. The pathophysiology of cephalic arch stenosis (CAS) is still being investigated and various contributing factors have been suggested. The treatment options for CAS are many and include angioplasty, endovascular stent insertion, access flow reduction and surgical interventions, but none of the current modalities are ideal. Therefore, the treatment of CAS is difficult, as the stenosis in this area tends to recur leading to the need for repeat angioplasty, stents or surgical revision. A 57-year-old woman undergoing hemodialysis (HD) through a right brachiocephalic arteriovenous fistula was found to have high venous pressure during HD and prolonged bleeding after HD. Clinical examination revealed a hyperpulsatile fistula suggestive of outflow obstruction. Doppler ultrasound examination showed cephalic vein thrombosis, severe outflow stenosis and juxta-anastomotic area. A 10 x 40 mm stent (Cordis Smart stent) was positioned appropriately in the cephalic arch and deployed, the stenotic lesion in juxta-anastomotic area was dilated with angioplasty balloon with improvement in flow. After 14 months, the fistula is still working perfectly with adequate flow.

[Prototyping a new registry of vascular accesses for hemodialysis].

We have developed a new registry of the Vascular Accesses (VA) of all the patients afferent to our health district in order to improve their management. We recorded all the VAs of the prevalent patients on 12/31/2017. The VA type and location, the vessels involved, the number of surgical procedures received by the patient and the kind of anastomosis of the VA were all recorded. As for Central Venous Catheters (CVC), we recorded the reason for the choice as well as the site and the characteristics of CVC. Results: The VA of 726 prevalent patients were registered. Their age was 66+15 years on average, and 63% were male. The native arteriovenous fistulas (AVF) were 609 (84%), of which 65% were located on the distal forearm (DF), 10% on the middle forearm (MF), 5% on proximal forearm (PF), 4% on the arm (AM). The arteriovenous Grafts (AVG) were 12 (1.7%). The CVCs were 105 (14.5%). More women than men received a CVC (p<0.005) or an AVF on the AM (p<0.05). Patients over 75 had less FAVs in the AM (P<0.05) and less Grafts (P<0.05). Diabetics patients had more CVCs (p<0.05) but were generally older (p<0.001). Patients in HD for renal transplantation loss had more AVFs at the arm (p<0.001) and Grafts (p<0.001), and less AVFs on the DF (p>0.001). The comparison of data between 2013 and 2017 shows a steady situation in the prevalence of VA. Conclusions: The new VA registry has allowed us to detect and record important information, both from a clinical and an epidemiological point of view.

[Acute kidney injury and rhabdomyolysis after cocaine overdose: case report and literature review].

Cocaine, a natural alkaloid derived from the coca plant, is one of the most commonly used illicit drugs. Cocaine abuse causes systemic adverse effects like stroke, myocardic infarction, arterial dissection, vascular thrombosis and rhabdomyolysis. Cocaine use is, also, associated with renal complications such as acute kidney injury, vasculitis, acute interstitial nephritis, chronic kidney disease, malignant hypertension with thrombotic microangiopathy. Acute kidney injury may or may be not associated to rhabdomyolysis. Rhabdomyolysis caused by cocaine abuse is multifactorial, involving tissue ischemia secondary to vasoconstriction and cellular damage caused by the drug. We report a 50-year-old man with history of chronic hepatitis C and substance abuse admitted to our unit with severe rhabdomyolysis and acute kidney failure after nasal insufflation of cocaine overdose. Renal function recovered after several treatments of dialysis. We conclude that cocaine adversely impacts kidney function ; in addition cocaine and rhabdomyolysis are the double danger for acute kidney injury. Medical management of cocaine toxicity requires a multisystem approach, with close monitoring cardiac, neurological and renal function.

Crossed fused renal ectopia: case report and review of the literature.

Crossed fused renal ectopia is a rare congenital anomaly, and is mostly detected incidentally. A 45-year-old man, during investigation for recurrent abdominal pain, was found to have an empty left renal fossa and right crossed renal ectopia with fusion on ultrasonography. In the present case, there were no abnormalities and/or alteration of the renal function. Abdominal tomography scan with contrast medium confirmed the diagnosis. Ectopic kidney is often associated with other abnormal situations such as agenesis, vascular malformation, incontinence, a palpable abdominal mass, urinary tract infection, high incidence of stone formation, and genital anomalies. Through this case report, we emphasize the importance of adequate imaging.

Echo color Doppler ultrasound: a valuable diagnostic tool in the assessment of arteriovenous fistula in hemodialysis patients.

A functioning vascular access is a critical requirement to improve the quality of life in hemodialysis patients, so monitoring and surveillance of vascular access play key roles in identifying all dysfunctions and reducing the huge economic cost as well as adequacy of dialysis.In our five-year experience, a study protocol has been used and improved with the help of ultrasonography.Doppler ultrasound is an excellent and sensitive modality for hemodialysis access evaluation, one of techniques employed for arteriovenous fistulae (AVF) study, not only as a preoperative tool, but also in post-operative monitoring of AVF maturation. In addition, the current guidelines recommend AVF surveillance by access blood flow measurement and the correction of hemodynamic stenosis in order to prolong access survival. Doppler ultrasound is readily available, directly used by nephrologists, non-invasive, safe, inexpensive, reproducible, although it requires more clinical skill and time to perform and proper equipment. Ultrasonography imaging can substantially reduce the number of subsequent invasive angiographic procedures. In our opinion, Doppler ultrasound should have a crucial place in the interdisciplinary cooperation in AVF monitoring and it should be included as part of an integrated vascular access management program.

[Takotsubo cardiomyopathy recurrence in patient with chronic kidney disease: case report and literature review]. / Recidiva di cardiomiopatia Takotsubo in paziente con insufficienza renale cronica: analisi di un caso clinico e revisione della letteratura.

Takotsubo cardiomyopathy (CT) is a syndrome characterized by an acute and transient left ventricular dysfunction, electrocardiographic abnormalities suggestive of acute coronary syndrome, chest pain and/or dyspnea, left ventricular mid-apical segments akinesia and normal coronary angiography. It is mainly observed in postmenopausal women after an intense physical or mental stress. The course is usually favourable but sometimes severe complications occur. The recurrence rate is 2-10%. We present the case of a recurrence of CT in a female, 79 years old, with hypertension, diabetes, chronic kidney disease (CKD) stage 3 who was admitted to the emergency room for dyspnea and vomiting. The electrocardiogram (ECG) showed a sinusal rhythm and T wave inversion in the pre-cordial leads and the echocardiogram a typical feature of CT with depressed left ventricular systolic function (FE). The ECG ranged quickly with atrial fibrillation rhythm, followed by a major hypokinetic arrhythmia with advanced atrio-ventricular block which indicated the need for a temporary pacemaker placement. The patient was oligouric, with severe renal failure, hyponatremia, hyperkalemia and metabolic acidosis. A continuous renal replacement therapy (CRRT) was started. On the seventh day improvement in urine output, electrolyte and acid base imbalance and FE normalization occurred. The renal function improved gradually, but after 36 months, persisted CKD stage 4. The case report describes the development of a cardiorenal syndrome type 1 induced by CT recurrence and effectiveness of CRRT in the management of acute heart failure. It also suggests a potential role played by CKD as a risk factor in the onset and recurrence of CT.

[Lactic acidosis, acute renal failure and heart failure during treatment with metformin: what do we know?]. / Acidosi lattica, insufficienza renale acuta e insufficienza cardiaca in corso di terapia con metformina: cosa sappiamo?

Metformin is a common medication used for the treatment of type 2 diabetes, especially in obese subjects. Clinical studies show that, in addition to the lowering effect of blood glucose, metformin reduces cardiovascular risk, does not induce weight gain and additionally, provides a unique safety strategy and efficacy in patients with diabetes and heart disease. However, this treatment is not without risks. The most feared metabolic complication is lactic acidosis that often occurs with complex and severe clinical symptoms and is associated with a high mortality risk. We detail our experience, during one year, regarding four patients with diabetes treated with metformin who developed such acute renal failure and lactic acidosis as to require hemodialysis treatment. The patients selected had previous normal renal function but a history of serious cardiovascular disease (hypertensive cardiomiopathy, ischemic revascularized and/or dilated, chronic obstructive arterial disease). We observed in all four of our patients an onset of non-related symptoms (fever, fatigue, vomiting and gastrointestinal disorders), a rapid deterioration in renal function, anuria and very high levels of lactic acid. In two patients we found acute pancreatitis. In addition to rehydration therapy, hemodialysis was started instantly with progressive rebalancing of the biohumoral status, effective recovery of spontaneous diuresis and improvement of the clinical status in three patients. Unfortunately, we had a failure during the initial hours of ward admittance, with an important clinical situation complicated by acute cardiac ischemia, abnormal heart rhythm, ending in death. Our experience provides us with elements to reflect on. Lactic acidosis is a serious metabolic disorder because it is associated with a high mortality risk. So a rapid diagnosis and a complete recognition of all the fundamental elements are important for its management. Starting hemodialysis early and prolonged treatment can solve complicated clinical status, correct acidosis and restore kidney function in patients with serious comorbidity.

[Horseshoe kidney: not a simple fusion anomaly]. / Rene a ferro di cavallo: non è una semplice anomalia di fusione. Analisi di due casi clinici e revisione della letteratura.

The horseshoe kidney is a congenital anatomical defect of the kidney that occurs in 0,25% of the population and is generally characterized by the fusion of the lower poles of the two kidneys through an isthmus and to which may be associated with urogenital and renal vascular anomalies. Asymptomatic in 1/3 of the cases and, most of time, accidentally discovered during a radiological examination, promotes nephrolithiasis, ureteropelvic junction obstruction, hydronephrosis, vesicoureteral reflux and pyelonephritis. We report two cases of patients with kidney horseshoe, characterized by the abrupt onset of a septic state with oligo-anuric acute renal failure, electrolyte and acid-base abnormalities, rapid decay of the general conditions, with detection of nephrolithiasis, hydronephrosis and acute pyelonephritis and whose clinical management resulted in a significant and synergistic nefro-urology involvment. The kidney horseshoe not represent so only a simple fusion anomaly but rather an important anatomical condition that, once diagnosed, it would be worthy of a careful clinical, radiological and laboratory surveillance, in order to prevent the potential complications that may be also particularly severe.

Bladder neck disease and kidney damage.

Primary bladder neck obstruction (PBNO) was first described in men by Marion in 1933. The precise cause of PBNO has not been clearly elucidated. This paper review the theories on etiology, clinical presentation, diagnostic evaluation and treatments for PBNO. Also this paper focuses on management of patients with complications like acute urine retention, hydroureteronephrosis and severe renal failure. The treatment options for men and women with PBNO include careful clinical evaluation, pharmacotherapy with alpha-blockers and surgical intervention.

Role of ultrasound in management of long-term complications after to radical cystectomy and orthotopic neobladder construction: case report.

Radical cystectomy with urinary diversion is considered the gold standard treatment for bladder cancer. We report a case of 66-years-old male with long term complications, after radical cystectomy and an ileal neobladder according to Hautmann. He developed uroseptic episodes, stones, post-void residual, stenosis of the uretero-neobladder anastomosis, metabolic acidosis and progressive deterioration of renal function. Renal ultrasound helped us to identify the dilation of the urinary tract, the grade of hydronephrosis and the presence of stones. During the follow-up, it is very important the collaboration between urologist and nephrologist and the role of ultrasound for an early correction of the hydronephrosis and the elective replacement of the stents in order to preserve the renal function.

[A case of arteriovenous fistula stenosis treated with percutaneous transluminal angioplasty]. / Un caso di stenosi serrata post-anastomotica di fistola arterovenosa trattata con angioplastica percutanea trans-luminale.

Arteriovenous fistula (AVF) is considered the gold standard for vascular access in hemodialysis, even in elderly patients. Malfunction of AVF is the first cause of hospitalization in the HD population, with a correlated increase in costs. For the monitoring and surveillance of fistulas, the 2006 K/DOQI workgroup recommends physical examination, direct flow measurement, Doppler ultrasonography and recirculation (by a non-urea-based dilutional method). We report the case of a 67-year-old woman affected by AVF stenosis. Combined AVF surveillance with recirculation and Doppler ultrasonography permitted early diagnosis and treatment with percutaneous angioplasty.