[NOACs and Chronic kidney disease].

Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, AF is associated with an increased risk of thromboembolism and stroke, according to progressive decline of glomerular filtration rate (GFR). However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25 ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with advanced chronic kidney disease (creatinine clearance <25 ml/min) and those on dialysis.

[Non vitamin-K dependent oral anticoagulants (NOACs) in chronic kidney disease patients with non-valvular atrial fibrillation].

Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, AF is associated with an increased risk of thromboembolism and stroke, according to progressive decline of glomerular filtration rate (GFR). However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25 ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with advanced chronic kidney disease (creatinine clearance <25 ml/) and those on dialysis.

Penile calciphylaxis in end stage renal disease.

Calciphylaxis, better described as "Calcific uremic arteriolopathy" (CUA), involves about 1-4% of hemodialysis patients all around the world with high mortality rates. We describe a rare clinical case of CUA in peritoneal dialysis patient associated with urological disease. Penile calciphylaxis represents rare clinical complication, and an early diagnosis and multidisciplinary approach are requested. Pathogenesis is still unclear, and therapeutic approaches need more long-term clinical trials to test their efficacy and safety.

[Calciphylaxis: an enigma to the nephrologist]. / Calcifilassi: un enigma per il nefrologo.

Calcific uremic arteriopathy (CUA), also known as calciphylaxis, is a rare condition occurring in patients with moderate to severe chronic kidney disease. It is a serious, debilitating and potentially fatal clinical disorder affecting 1-4% of the dialysis population and is associated with a high mortality rate (60-80%). The clinical picture is characterized by painful skin lesions tending to necrotic or gangrenous ulceration ultimately necessitating amputation. Severe infectious complications leading to sepsis and death are frequent. The pathogenesis of CUA is still unknown and several pathogenetic hypotheses have been put forward; this makes its treatment difficult and often empirical. The current paper presents a systematic review of recent findings on the pathogenesis, diagnosis and treatment of CUA.

[The nephrologist and the role of ultrasound imaging in the diagnosis of cardiorenal syndrome]. / Il nefrologo e il ruolo dell'imaging ultrasonografico nella diagnosi di sindrome cardio-renale.

The term cardiorenal syndrome (CRS) refers to multiple possible clinicopathological correlations between heart and kidney failure. The most recent classification recognizes five types of CRS: types I and II originate from heart failure (acute and chronic, respectively), type III and IV from kidney failure (again acute and chronic), while type V originates from a range of systemic diseases. Echocardiography and renal ultrasound are important means to arrive at a correct diagnosis. Basic echocardiography (defined by some as "echocardioscopy") allows the assessment of the left and right ventricles (diastolic and systolic function), atrial size, pulmonary circulation markers such as systolic pulmonary arterial pressure (PAPs) and tricuspid annular plane excursion (TAPSE), pericardial effusions, valve dysfunctions, and volume repletion. Renal ultrasound is of help in distinguishing between chronic and acute renal failure (kidney volume, parenchymal thickness, echogenicity) and excluding obstructive kidney disease.