Increase of continuous treatments and regional citrate anticoagulation during renal replacement therapy in the ICUs of the North-West of Italy from 2007 to 2015.

BACKGROUND: Few reports have addressed the change in renal replacement therapy (RRT) management in the Intensive care Units (ICUs) over the years in western countries. This study aims to assess the trend of dialytic practice in a 4.5-million population-based study of the northwest of Italy. METHODS: A nine-year survey covering all the RRT provided in the ICUs. Consultant nephrologists of the 26 Nephrology and Dialysis centers reported their activities in the years 2007, 2009, 2012, and 2015. RESULTS: From 2007 to 2015 the patients treated increased from 1042 to 1139, and the incidence of RRT from 254 to 263 cases/10^6 inhabitants. The workload for dialysis center was higher in the larger hub hospitals. RRT for acute kidney injury (AKI), continuation of treatment in chronically dialyzed patients, or extrarenal indications accounted for about the stable rate of 70, 25 and 5% of all RRT sessions, respectively. Continuous modality days increased from 2731 days (39.5%) in 2007 to 5076 (70.6%) in 2015, when the continuous+prolonged treatment days were 6880/7196 (95.6% of total days). As to RRT timing, in 2015 only the classical clinical criteria, and no K-DIGO stage were adopted by most Centers. As to RRT interruption, in 2015 urine volume was the first criterion. Implementation of citrate anticoagulation (RCA) for RRT patients significantly increased from 2.8% in 2007 to 30.9% in 2015, when it was applied in all 26 Centers. CONCLUSIONS: From 2007 to 2015, current practice has changed towards shared protocols, with increasing continuous modality and RCA implementation.

Weight Loss in Advanced Chronic Kidney Disease: Should We Consider Individualised, Qualitative, ad Libitum Diets? A Narrative Review and Case Study.

In advanced chronic kidney disease, obesity may bring a survival advantage, but many transplant centres demand weight loss before wait-listing for kidney graft. The case here described regards a 71-year-old man, with obesity-related glomerulopathy; referral data were: weight 110 kg, Body Mass Index (BMI) 37 kg/m², serum creatinine (sCr) 5 mg/dL, estimated glomerular filtration rate (eGFR) 23 mL/min, blood urea nitrogen (BUN) 75 mg/dL, proteinuria 2.3 g/day. A moderately restricted, low-protein diet allowed reduction in BUN (45-55 mg/dL) and good metabolic and kidney function stability, with a weight increase of 6 kg. Therefore, he asked to be enrolled in a weight-loss program to be wait-listed (the two nearest transplant centres required a BMI below 30 or 35 kg/m²). Since previous low-calorie diets were not successful and he was against a surgical approach, we chose a qualitative, ad libitum coach-assisted diet, freely available in our unit. In the first phase, the diet is dissociated; he lost 16 kg in 2 months, without need for dialysis. In the second maintenance phase, in which foods are progressively combined, he lost 4 kg in 5 months, allowing wait-listing. Dialysis started one year later, and was followed by weight gain of about 5 kg. He resumed the maintenance diet, and his current body weight, 35 months after the start of the diet, is 94 kg, with a BMI of 31.7 kg/m², without clinical or biochemical signs of malnutrition. This case suggests that our patients can benefit from the same options available to non-CKD (chronic kidney disease) individuals, provided that strict multidisciplinary surveillance is assured.

Neutrophil Gelatinase Associated Lipocalin Is an Early and Accurate Biomarker of Graft Function and Tissue Regeneration in Kidney Transplantation from Extended Criteria Donors.

BACKGROUND: Delayed graft function (DGF) is an early complication of kidney transplantation (KT) associated with increased risk of early loss of graft function. DGF increases using kidneys from extended criteria donors (ECD). NGAL is a 25KDa protein proposed as biomarker of acute kidney injury. The aim of this study was to investigate the role of NGAL as an early and accurate indicator of DGF and Tacrolimus (Tac) toxicity and as a mediator of tissue regeneration in KT from ECD. METHODS: We evaluated plasma levels of NGAL in 50 KT patients from ECD in the first 4 days after surgery or after Tac introduction. RESULTS: Plasma levels of NGAL at day 1 were significantly higher in DGF group. In the non DGF group, NGAL discriminated between slow or immediate graft function and decreased more rapidly than serum creatinine. NGAL increased after Tac introduction, suggesting a role as marker of drug toxicity. In vitro, hypoxia and Tac induced NGAL release from tubular epithelial cells (TEC) favoring an autocrine loop that sustains proliferation and inhibits apoptosis (decrease of caspases and Bax/Bcl-2 ratio). CONCLUSIONS: NGAL is an early and accurate biomarker of graft function in KT from ECD favoring TEC regeneration after ischemic and nephrotoxic injury.

[ABO-incompatible kidney transplantion]. / Controversia: il trapianto renale ABO-incompatibile.

The widespread worldwide implementation of ABO-incompatible kidney transplantation (ABOi KT) programs have increased the chances of gaining access to kidney transplantation. In Italy the practice of ABOi KT has somewhat lagged behind that practiced in many other European Countries. Even though some Italian Transplant Centers have recently started ABOi KT programs, most of them appear still reluctant in adopting this procedure. In this paper, nephrologists from two different Italian Transplant Centers express their contrasting point of view concerning specific issues related to ABOi KT. The first issue concerns the safety and efficacy of ABOi KT and how it compares with HLA-incompatible kidney transplantation. The second concerns to what extent does ABOi KT be adopted, whenever a paired kidney exchange program is available. The third issue regards the indications or contraindications of ABOi KT in specific patient categories. The last issue is about the economical sustainability of ABOi KT programs nowadays. The different point of views of the discussants are summarized in the context of the most recent available evidence.

Teenagers' point of view on living donor kidney transplantation: Cinderella or princess?

UNLABELLED: Living kidney donation is an important clinical option, encountering different fortunes in the world. AIM: To analyse the opinions of a large subset of older teenagers attending high school (7999 students, median age 18) on different aspects of living kidney transplantation. METHODS: Analysis of semistructured questionnaires submitted within an educational campaign on dialysis and transplantation in the high schools of Torino and its county (about 2,000,000 inhabitants). RESULTS: Over 90% of the students had already heard of transplantation, mainly via television (88.4% county, 84.5% city). 80% would donate a kidney to a family member (3.5% wouldn't, 16.5% uncertain); answers were correlated with sex (females more than males p<0.0001), school type (istituti tecnici versus licei p=0.007), interest (yes versus other p<0.0001). A lower percent of individuals would receive a kidney (58.4% county, 59.4% city), only 10% would ask for donation. Over 40% of students consider legally buying a kidney a patient's right, only 26.6% would discourage this choice. The answers were correlated with the reverse pattern as for non-mercenary donation with type of school (licei more than istituti tecnici: p<0.0001), sex (males versus females p<0.0001), interest (not versus yes: p=0.002). CONCLUSIONS: Teenagers are favourable towards all forms of living kidney donation. The lower prevalence of positive answers on acceptance versus donation suggests that fears of endangering the donor's health may be one of the causes for a low living donation rate in our setting. The mixed answers on mercenary donation suggest discussing this complex issue in future educational programs.