[Report of the National Renal Ultrasound Study Group on the ultrasound activity of nephrology care units in Italy]. / Report del gruppo di studio nazionale di ecografia renale sull'attivita' ecografica delle U.O. di Nefrologia in Italia.

The presence of operational and organizational differences in the use of ultrasonography in Italian nephrology units has prompted this survey on a nationwide scale. The survey was carried out by questionnaire and included questions about the activity and equipment of each nephrology unit, dedicated personnel and relevant training, and the fields of ultrasonography application. Seventy-five percent of the contacted care units replied to the questionnaire. Twenty-six percent of these performed their ultrasound examinations outside the care unit, sharing equipment with other units. The mean lifetime of ultrasound devices was longer (5.8 years) than allowed by the electro-medical equipment regulations. In spite of an increasing number of nephrologists with ultrasonographic expertise, in each care unit the percentage of physicians performing ultrasound examinations was very low. The number of operators who learned this methodology directly at surgeries using ultrasound devices was higher than that of operators who attended training courses and obtained the relevant certificates. In addition to the kidneys and urinary tract, other body districts investigated included abdominal organs, parathyroids, vascular access for hemodialysis treatment, and the bone-joint system. Moreover, ultrasonography was widely used for surgical procedures in nephrology. However, in spite of the widespread application of ultrasound imaging, the use of radiology was unexpectedly high (80%). Finally, the questionnaire results evidenced the particular care of nephrologists towards follow-up for situations of nephrological interest, such as acquired renal cysts, vascular access visualization, and monitoring of parathyroids.

[Role of the ultrasound and color-Doppler in the progression of the renal damage]. / Ruolo dell'ecografia e dell'eco-color-Doppler nella progressione del danno renale.

Ultrasound (US) evaluation of the urinary tract in nephrological settings provides the right assessment of many clinical pictures. Actually it allows a realtime differentiation between parenchymal lesions, obstructions or tumoral masses. On the contrary the differential diagnosis of parenchymal nephropathies appears more difficult due to the fact that different histological pictures may present similar ultrasound findings. The echo-color-Doppler is a valid integration of the conventional US B-mode technique thanks to the measurement of some indirect parameters such as the resistance index (RI) and the pulsatility index (PA). It has been showed that the IR results higher in patients with tubulo- interstitial or vascular nephropathies than in those with glomerular ones. It is still debated the relationship between IR and the progression of the renal damage. In the recent years the RIs have gained importance as vascular compliance surrogates: actually their rise has been observed both in cases of vascular damages and in systemic atherosclerosis or associated with other features of renal damage. More studies based on sophisticated US techniques are warranted in order to make the US as golden standard for the diagnosis of parenchymal nephropathies.

[When a bubble bursts]. / Quando di rompe una bolla.

A 47-year-old man with a medical history of nephrolithiasis of the right kidney presented with abdominal pain at the level of the right hip. Ultrasonography showed an anechoic area with irregular contours in the lower pole of the right kidney, where a previous ultrasound scan had signalled the presence of a large cyst. Abdominal computed tomography revealed the presence of a fluid area within the lower pole of the right kidney. Subsequent ultrasonography showed progressive reduction of the anechoic area, which was associated with gradual reduction of the pain. The case was diagnosed as spontaneous rupture of a renal cyst. Renal cyst rupture is an infrequent, usually self-limiting event that may engender diagnostic dilemmas.

[A tricky issue for the ultrasound technician]. / Un rompicapo per l'ecografista.

A 72-year-old woman presented with chronic renal failure and diffuse abdominal pain. On ultrasonography the right kidney showed an uncommon site, whereas the left kidney presented a pseudo mass on its lower pole. MRI detected a multiple anatomic anomaly: dislocation of the right kidney, renal fusion, malrotation of the left kidney. This anatomic anomaly is called ''sigmoid kidney'': it can be asymptomatic or result in genitourinary diseases.

[A girl in the mirror]. / Una ragazza allo specchio.

We report a case of situs ambiguous associated with particular vascular anomalies resulting in secondary arterial hypertension. Renal ultrasonography performed in this case has oriented diagnosis.

[From symptom to diagnosis: but not always!]. / Dal sintomo alla diagnosi: ma non sempre!

The classic presentation of acute renal colic is the onset of severe flank pain associated to homolateral groin irradiation. Very often these patients present typical clinical diagnosis patterns. We present a case of nephrolithiasis with atypical characteristics. The exact diagnosis has been possible only after the release of the stone.

Global approach to cardiovascular risk in chronic kidney disease: reality and opportunities for intervention.

The current implementation into nephrology clinical practice of guidelines on treatment of cardiovascular (CV) risk factors in chronic kidney disease (CKD) is unknown. We designed a cross-sectional analysis to evaluate the prevalence and treatment of eight modifiable CV risk factors in 1058 predialysis CKD patients (stage 3: n=486; stage 4: n=430, stage 5: n=142) followed for at least 1 year in 26 Italian renal clinics. The median nephrology follow-up was 37 months (range: 12-391 months). From stages 3 to 5, hypertension was the main complication (89, 87, and 87%), whereas smoking, high calcium-phosphate product and malnutrition were uncommon. The prevalence of proteinuria (25, 38, and 58%), anemia (16, 32, and 51%) and left ventricular hypertrophy (51, 55, and 64%) significantly increased, while hypercholesterolemia was less frequent in stage 5 (49%) than in stages 4 and 3 (59%). The vast majority of patients received multidrug antihypertensive therapy including inhibitors of renin-angiotensin system; conversely, diuretic treatment was consistently inadequate for both frequency and dose despite scarce implementation of low salt diet (19%). Statins were not prescribed in most hypercholesterolemics (78%), and epoietin treatment was largely overlooked in anemics (78%). The adjusted risk for having a higher number of uncontrolled risk factors rose in the presence of diabetes (odds ratio 1.29, 95% confidence interval 1.00-1.66), history of CV disease (odds ratio 1.48, 95% confidence interval 1.15-1.90) and CKD stages 4 and 5 (odds ratio 1.75, 95% confidence interval 1.37-2.22 and odds ratio 2.85, 95% confidence interval 2.01-4.04, respectively). In the tertiary care of CKD, treatment of hypertension is largely inadequate, whereas therapy of anemia and dyslipidemia is frequently omitted. The risk of not achieving therapeutic targets is higher in patients with diabetes, CV disease and more advanced CKD.

[An unusual case of microhematuria]. / Un insolito caso di microematuria.

Microhematuria is nearly always due to renal parenchymal or genito-urinary damage, with few exceptions. We report a case of microhematuria due to vascular anomaly. The diagnosis was realized making use of several imaging techniques.

Intravenous ascorbic acid in hemodialysis patients with functional iron deficiency: a clinical trial.

BACKGROUND: Hemodialysis (HD) patients with functional iron deficiency (FID) often develop resistance to recombinant human erythropoietin (rHuEpo). In these patients, iron therapy may be a hazard, leading to iron overload and consequently to hemosiderosis. Recent studies suggest that intravenous ascorbic acid (IVAA) may circumvent rHuEpo resistance. The aim of our study was to show the effects of IVAA on FID and whether this results in a better correction of anemia in HD patients with stable hemoglobin (Hb) concentration and FID. METHODS: Twenty-seven HD patients with serum ferritin >300 microg/l, transferrin saturation (TS) <20% and hemoglobin (Hb) <10 g/dL were selected andrandomly divided into two groups to enter a cross-over trial with IVAA. In group I IV vitamin C 500 mg was administered three times a week for three months and discontinued in the next three months of the study. Vitamin C was not given the first three months in group II (control group, first three months of the study), who then received 500 mg IV three times a week for the next three months. RESULTS: Hb and TS% significantly increased (baselines vs 3 months, Hb 9.2 +/- 0.2 vs 10.0 +/- 0.3 g/dL, TS% 17.5 +/- 0.6 vs 25.7 +/- 1.7, respectively p < 0.01 and p <0.001) in group I after three months; ferritin fell significantly from 572 +/- 40 to 398 +/- 55 microg/L (p<0.004). Ten patients completed the study: mean Hb and TS% fell significantly (3 months vs final, Hb 9.9 +/- 0.3 vs 8.9 +/- 0.2 g/dL, TS% 25.1 +/- 1.2 vs 19.1 +/- 1.1, respectively p < 0.01 and p <0.001), while mean ferritin did not change. Mean Hb, ferritin and TS% remained unchanged in group II after three months. Hb and TS% mean values rose significantly (3 months vs final, Hb 9.0 +/- 0.2 vs 9.9 +/- 0.2 g/dl, TS% 18.4 +/- 1.0 vs 27.0 +/- 1.0, respectively p < 0.005 and p <0.001), and ferritin markedly decreased from 450 +/- 50 to 206 +/- 24 microg/L (p < 0.001) at the end of the study. The rHuEpo dose was kept unchanged throughout the study. Differences were analyzed after three months. Mean Hb rose (0.8 +/- 0.2 g/dL) in group I but dropped (-0.1 +/- 0.1 g/dL) (p< 0.009) in group II. Ferritin dropped in both groups (group I vs group II, -173 + /-48 vs - 33 +/- 21 microg/L) (p < 0.01) while TS% increased (group I vs group II, 8.2 +/- 1.5 vs 0.4 +/- 0.7) (p < 0.001). CONCLUSION: IVAA may partially correct FID and consequently help rHuEpo hyporesponsive anemia.

Urinary IL-6/EGF ratio: a useful prognostic marker for the progression of renal damage in IgA nephropathy.

Interleukin 6 (IL-6) is produced by human mesangial and tubular cells, and its urinary levels has been proposed as a marker of mesangial proliferation and tubulointerstitial damage. Epidermal growth factor (EGF) is expressed within the Henle's loop and the distal tubule and has been shown to accelerate recovery from renal injury. In the present study we have defined renal gene and protein expression of IL-6 and EGF in 10 normal, 10 nonproliferative glomerulonephritis (NPGN) and 30 IgA nephropathy (IgAN) human kidneys by RT-PCR, in situ hybridization and immunohistochemical techniques. Moreover, urinary IL-6 and EGF levels were measured in 41 patients with IgAN and in 20 normal subjects (N). In normal kidneys, EGF was localized in Henle's loop and distal convoluted tubule whereas IL-6 was mainly located in the proximal tubule and, less, within the glomerulus. In IgAN patients, EGF was decreased whereas IL-6 expression was upregulated. These modifications paralleled the degree of tubulointerstitial damage. Moreover, IgAN patients as a whole exhibited a reduction of EGF and an increase of IL-6 urinary concentration (EGF values: N, 12.96 +/- 1.15; IgAN Grades 1-2, 20.05 +/- 2.64; Grades 3-4 7.60 +/- 1.70: Grade 5, 3.14 +/- 0.71, ng/mg urinary creatinine. IL-6 values: N, 2.04 +/- 0.51; IgAN Grades 1-2, 3.26 +/- 0.38; Grades 3-4, 5.67 +/- 0.92; Grade 5, 27.20 +/- 9.70 pg/mg urinary creatinine), that correlated with the degree of histological lesions, the presence of hypertension and serum creatinine level. Interestingly, patients with the highest urinary IL-6/EGF ratio showed a worse evolution in a three year follow-up. In conclusion, our data show that: (1) renal IL-6 and EGF expression are strictly correlated to the degree of tubulointerstitial damage; and (2) urinary IL-6/EGF ratio might be a valuable prognostic marker for the progression of the renal damage in IgAN.

HCV infection occupational hazard at dialysis units and virus spread, among relatives of dialyzed patients.

It was the purpose of this study to evaluate the spread of HCV infection among the staff at Dialysis Units and among relatives of anti-HCV-positive hemodialysis patients. 122 health-care workers and 52 relatives were screened for presence of anti-HCV Ab. The control groups consisted of 100 health-care workers from other wards and 30 relatives of anti-HCV-negative subjects. 2.45% of the health-care staff and 5.8% of the relatives were found to be anti-HCV Ab carriers. None of the subjects in the control groups were positive. In conclusion, the results of this study indicate that there is a real possibility of HCV spread through occupational exposure although the corresponding percentage in less than that presumably due to within-the-family contagion by the virus.

Pathogenetic aspects of uremic cardiomyopathy.

We have considered just some of the many factors which may affect myocardial function, assessed by means of echocardiography, in uremic patients. Our findings support the view of a multifactorial genesis of the cardiac involvement in uremic patients.