Introduction to the Rome Declaration.

BACKGROUND: The Global Health Summit was held in Rome on 21 May 2021, co-hosted by the European Commission and Italy, as chair of the G20. Leaders, heads of regional and international organizations met to share lessons learned from the COVID-19 pandemic and to define the path ahead. OBJECTIVE: The present paper analyses the Rome Declaration as the first global health programme shared among the G20 Member States and based on the One-Health approach. METHODS: Documents such as preparatory work, official documents and observations from international organizations were analysed in order to provide a comprehensive review of the Rome Declaration. RESULTS: Core principles of the Rome Declarations have emerged as well as the goal to improve cooperation among existing international organisations and national authorities. CONCLUSIONS: Governments' future decisions will be the key to determine the end of the pandemic. The interconnected impacts on health, the environment, and social and economic dimensions will be a central theme of the overall narrative aiming at bringing the G20 process towards achieving a more inclusive and sustainable society.

Low incidence of nephrotoxicity following intravenous administration of iodinated contrast media: a prospective study.

OBJECTIVES: To estimate the incidence of contrast-induced acute kidney injury (CI-AKI) after intravenous (iv) iodinated contrast material (ICM) exposure. METHODS: This prospective cohort study included all consecutive patients who underwent radiological investigations using low-osmolar iopamidol 370 mg/ml in a regional hospital over a period of 36 months, without any exclusion criteria. The estimated glomerular filtration rate (eGFR) was evaluated using the MRDR equation before (2-10 days) and after (24-36 h) radiological investigations. CI-AKI was defined as a ≥ 25% decrease in eGFR from baseline. CI-AKI incidence was estimated using a binomial distribution. The association between CI-AKI and demographic and clinical characteristics was modeled using logistic regression. RESULTS: The study included 1541 patients with a median age of 68 (1st-3rd quartiles 58-76) years with various comorbidities, 30% of whom had pre-existing CKD. Patients affected by stage III or IV chronic kidney disease (CKD) received an infusion of 0.9% normal saline (1.0-1.5 ml/kg/h) before and after iso-osmolar iodixanol administration. CI-AKI was observed in 33 patients (2.1%, 95% CI 1.5-3.0). The logistic regression analysis showed that antibiotic and statin therapies were significantly associated with CI-AKI. The probability of developing CI-AKI decreased by 80% in patients taking statins (OR = 0.20, 95% CI 0.03; 0.68) and increased approximately three times in patients with antibiotic therapy compared with those who did not take statins and antibiotics (OR = 2.92, 95% CI 1.21; 6.36). CONCLUSIONS: Our data suggest that low-osmolar iopamidol carries a low incidence of nephrotoxicity, even in subjects with various comorbid conditions or reduced renal function. KEY POINTS: • IV administration of ICM carries a low incidence of nephrotoxicity, which was transient in observed patients. • Statin therapy is negatively associated with AKI in patients exposed to ICM. • Pre-existing impairment of renal function is not associated with AKI in patients exposed to ICM.

Kidney transplantation in patients with previous renal cancer: a critical appraisal of current evidence and guidelines.

Due to the increasing occurrence of renal cell carcinoma (RCC) in the general population and the high prevalence of chronic kidney disease among cancer patients, many people with a previous RCC may eventually require renal replacement therapy including kidney transplantation. They should accordingly be evaluated to assess their life expectancy and the risk that the chronic immunosuppressive therapy needed after grafting might impair their long-term outcome. Current guidelines on listing patients for renal transplantation suggest that no delay is required for subjects with small or incidentally discovered RCC, while the recommendations for patients who have been treated for a symptomatic RCC or for those with large or invasive tumours are conflicting. The controversial results reported by even recent studies focusing on the cancer risk in kidney graft recipients with a prior history of malignancy do not help to clarify the doubts arising in everyday clinical practice. Several tools, including integrated scoring systems, are currently available to assess the prognosis of patients with a previous RCC and, although they have not been validated in subjects receiving long-term immunosuppressive drugs, they can be used to identify patients suitable to be listed for grafting. Among these, the Leibovich score is currently the most widely used as it has proved simple and reliable enough and helps categorize renal transplant candidates. According to this system, subjects with a score from 0 to 2 are at low risk and may be listed without delay, while those with a score of 6 or higher should be excluded from grafting. In addition, other factors have an established positive prognostic value, including chromophobe or clear cell papillary tumour, or G1 grade cancer; on the contrary, medullary or Bellini's duct carcinoma or those with sarcomatoid dedifferentiation at histological examination should be excluded. All other patients would be better submitted to careful individual evaluation by an Oncologist before being listed for renal transplantation, pending studies specifically focusing on cancer risk evaluation in people already treated for malignancy receiving long-term immunosuppressive therapy.

[Hemodialysis and cardiovascular outcome].

Hemodialysis patients often present multiple comorbidities and have a high mortality rate (15-20% per year), mostly due to cardiovascular events. Besides predisposing pathological conditions related to uremia (heart failure, coronary heart disease, left ventricular hypertrophy, arrhythmias), they also have specific risk factors linked to the hemodialysis (HD) treatment in itself: chronic inflammation, fluid overload, autonomic nervous system dysfunction, arterovenous fistula. These factors may affect the hemodynamic compensatory systems (vascular refilling, arteriolar and venous tone, autonomic nervous system response) to fluid removal, with high risk of intra-dialysis hypotension (IDH) episodes or arrhythmic events. IDH is recognized as associated to a negative long term outcome, due to the repeated episodes of organ hypoperfusion with ischemic damage to heart, brain and gut. Over the years, dialysis technology has greatly improved, with the development of continuous and noninvasive monitoring systems, able to control some hemodynamic parameters affecting blood pressure (mainly blood volume and body temperature), with positive results in terms of hemodynamic instability during HD. Furthermore, recent studies suggest that hemodiafiltration may reduce the risk of IDH and cardiovascular mortality, compared with conventional HD. Diabetic and/or old patients, as well as those with a previous cardiovascular event, are the first patients who should receive the new treatment options. Overall, the HD prescription needs to be tailored to each patient's need, to improve the hemodynamic tolerance to treatment and the cardiovascular outcome.

[Renal toxicity of antiviral drugs]. / Il danno renale da farmaci antivirali.

Highly effective and powerful antiviral drugs have been introduced into clinical practice in recent years which are associated with an increased incidence of nephrotoxicity. The need of combining several drugs, the fragility of the patients treated, and the high susceptibility of the kidney are all factors contributing to renal injury. Many pathogenetic mechanisms are involved in the nephrotoxicity of antiviral drugs, including drug interaction with transport proteins in the tubular cell; direct cytotoxicity due to a high intracellular drug concentration; mitochondrial injury; and intrarenal obstruction or stone formation due to the low solubility of drugs at a normal urinary pH. As a result, various clinical pictures may be observed in patients treated with antiviral drugs, ranging from tubular dysfunction (Fanconi syndrome, renal tubular acidosis, nephrogenic diabetes insipidus) to acute renal failure (induced by tubular necrosis or crystal nephropathy) and kidney stones. Careful attention should be paid to prevent renal toxicity by evaluating the glomerular filtration rate before therapy and adjusting the drug dosage accordingly, avoiding the combination with other nephrotoxic drugs, and monitoring renal parameters on a regular basis while treating patients.