[Bad news in nephrology]. / ''Deve iniziare la dialisi...'' La cattiva notizia in nefrologia.

The impact with a diagnosis of terminal chronic kidney failure produces a strong reaction in the patient, who feels confused, scared, angry and often expresses his scepticism about the physician's competence. It as been observed that the physician's attitude during his first contact with the patient determines the features of the patient's approach to the disease and its treatment. Respect, tact, empathy, support and information precision are essential to the establishment of a productive communication relationship resulting in a satisfying level of patients' awareness and compliance. A group of 80 patients was surveyed with a semi-structured interview aimed at evaluating physicians' communication strategies and patients' emotional experience. In order to improve the patients' life quality by making him an active part of every step of his treatment, is strongly recommended the adoption of a patient-centred communication pattern based on contact and positive unconditioned acceptance.

[A closed cycle]. / Un ciclo chiuso.

A young girl was admitted to the Renal Unit of our Hospital because of loin pain and mild renal failure with bilateral hydronephrosis. The abdomen ultrasound was very helpful to get the right diagnosis.

[Twinkling artifact in kidney stone disease]. / Arlecchino e la calcolosi urinaria.

BACKGROUND: Ultrasonography artifacts are false representations of the image caused by the interaction between the ultrasound and the tissues. The ability to identify artifacts is an important source of information that can help the clinician in performing a correct diagnosis. The twinkling artifact (called 'Effetto Arlecchino' by the Italians) consists of a series of colored pixels that appear inside, around and often along the shadow cone of the calculi. METHODS: We evaluated the clinical effectiveness of this artifact in the diagnosis of kidney stone disease. In 107 ultrasonography cases of hyperechogenic formations with clinical features of kidney stones, we used the color box to evoke the twinkling artifact. Of the 107 cases, 102 cases (95%) presented this artifact, while five cases did not. Moreover, this artifact was present in all urethral and bladder stones and in 62/67 kidney stone cases. CONCLUSIONS: In our experience, we found that the twinkling artifact is often positive in urinary stone disease, and the ability to identify it adds useful information to the diagnosis of urinary kidney stone disease.

The management of hemodialysis arteriovenous fistulas in well functioning renal transplanted patients: many doubts, few certainties.

UNLABELLED: Vascular access (VA) for hemodialysis (HD) is one of the most important clinical problems in end-stage renal disease (ESRD) patients because it can limit a life support system and can influence long-term dialysis patient survival. Nevertheless, VA becomes useless after a successful renal transplant. Therefore, we wanted to evaluate the natural history of arteriovenous fistulas (AVF) in renal transplanted patients and the possibility of maintaining the fistula as patent or not. METHODS: A retrospective study was conducted to evaluate kidney transplant patients in our unit from April 1994 to April 2004. We studied 542 patients. RESULTS: There were 365 patients with a well functioning kidney. Eighty-six patients died. Ninety-one patients were put back on dialysis: 89 patients on HD and two patients on CAPD. Of the 365 patients with functioning kidney transplants, 198 patients demonstrated a patent fistula, while 167 patients had a closed fistula. One hundred and twenty-five patients had a spontaneous closure and 42 patients had a surgical closure. Of the 89 patients put back on dialysis, 49 patients used the previous AVF, while it was necessary to create a new VA in 40 patients. CONCLUSIONS: As demonstrated by the results of our study, after renal transplantation the possibility of spontaneous AVF closure caused by a thrombosis is not a rare event. The dilemma is whether to preserve a fistula that could be useful in case of restarting HD or to perform a systematic fistula closure because of cardiac output and cardiac failure risks. Concerning this question there is no consensus between different authors in the literature. In reviewing the literature and analyzing our data, we conclude that the definite indications for AVF closure in well functioning renal transplanted patients are heart failure, high flow fistula, VA complications and important aesthetic reasons. Routine AVF closure is not indicated until prospective and randomized studies can demonstrate the ability of this procedure to reduce the high incidence of cardiac morbidity and mortality that is present, even after renal transplantation.