Giornale di Tecniche Nefrologiche e Dialitiche

The buttonhole technique (BT) is an alternative to the standard needling for the cannulation of arterio-venous fistula (AVF). The balance between benefits and harms associated with the BT is unclear.

In order to analyze the recent literature we searched PubMed for “randomized controlled study on buttonhole” and “review of buttonhole cannulation”, published between January 2011 and November 2013.

We identified 3 randomized trials and 3 reviews. One randomized trial showed a better survival of the AVFs (100% vs 82%), fewer interventions (19% vs 39%), and lower growth of pre-existing aneurysms (23% vs 67%) in the BT group. A second study showed a greater number of infections and hematomas, and a greater perception of pain in the BT group. A third study showed no differences in perception of pain and bleeding time between the BT group and the control group; additionally, it reported a greater number of hematomas in the control group and a greater number of local infections and sepsis in the BT group. The three reviews showed no definite results regarding the various endpoints of BT (perception of pain, aneurysm formation, bleeding time), and confirmed the increased risk of local and systemic infections.

Based on this analysis, we can conclude that the BT produces an increased risk of local and systemic infections without definite benefits. Recent studies suggest reserving the BT in selected cases (vessels particularly deep or too short stretches). However, we cannot exclude that further randomized controlled trials may lead to different conclusions on the BT.

Recently we observed a renewed interest in home hemodialysis for the treatment of chronic renal disease thanks to the latest technological innovations, which allow to undergo this treatment more easily than in the past. The revival of this method raises an interesting debate in the scientific community; this debate has shown some critical positions in Italy through the NephroMeet platform. In this paper we highlight the main clinical evidences and the psychological and social effects of home hemodialysis, through a revision of the most recent literature and the conversational analysis of a successful case. Our perspective starts from the concept of health as defined by the WHO. We show how home extracorporeal hemodialysis presents important advantages, both clinical and psychosocial, and why it should be considered as a valid alternative after transplantation and peritoneal dialysis.

Many recent papers analyze the association between renal stone disease and other diseases that are typical of industrialized countries. Epidemiology studies from large series indicate that the prevalence of nephrolithiasis is higher among patients with metabolic syndrome, diabetes, and hypertension. Patients with nephrolithiasis also have an increased risk of myocardial infarction and stroke. It has been hypothesized that the common underlying defect could be insulin resistance. This, in turn, alters the urine biochemistry (i.e. more acidic pH and less urine citrate) thereby increasing the propensity of stone forming. In the diabetic rat renal steatosis has been implicated in the reduced production of ammonia, which has been shown to be reversible after PPARγ administration. Furthermore, pioglitazone was shown to be effective in reducing ethylene glycol-induced renal injury.

Another significant association concerns gout. Two recent papers report that both calcium and uric acid stone disease are more prevalent among patients with gout. The metabolic derangements found in gouty and non-gouty patients were quite similar. CT imaging in patients with gout indicates that the incidence of nephrolithiasis is underestimated if only based on stone history. Finally, stone episodes may occur many years before the first gouty attack.

Another interesting issue is that of a potential adverse effect of calcium and vitamin D supplementation on the risk of stone formation. It has been shown that treated post-menopausal women have a slight but significantly higher risk of forming stones, independently of other interfering variables. From this the recommendation to evaluate the actual benefit of supplementation, even more in the face of its ineffectiveness to prevent fractures in older women.

Bariatric surgery is increasingly proposed for managing severe obesity, and in the last few years it has shown a widespread use in the US. Previous procedures of digestive diversion were often complicated by hyperoxaluria and renal oxalosis. More recent techniques, including Roux-en-Y gastric bypass and gastric bending, seem to give better outcomes. Hyperoxaluria and hypocitraturia following these procedures induce only minor increases in the risk of forming stones, but some recent reports of renal oxalosis after gastric bypass deserve attention.

Benzodiazepines, consisting of a benzene ring joined to a diazepine ring and a phenyl radical, are a class of drugs mainly used for the treatment of anxiety symptoms. They increase the transmission of gamma-aminobutyric acid (a kind of endogenous anxiolytic) and, therefore, they have an anxiolytic, sleep-inducing or sedative, myorelaxing, anticonvulsive, and anesthetic effect. They have minimal interactions with other drugs, but too often they are used as a long-term therapy instead of being used only when they are really necessary. The Territorial Pharmacist can play an important role in solving this problem. In patients with renal disease it is important to consider that the pharmacokinetics of these drugs, and therefore the absorption, degradation, and excretion of both their active principles and their metabolites are altered factors in case of kidney failure. Patients with renal disease make use of benzodiazepines more than the general population; however in these patients it is necessary to reduce the dose of about one third of the maximum dose allowed in patients with normal renal function. Additional research is also needed to investigate the main reasons of benzodiazepines use by patients with kidney disease.

Amyloidosis is a disease characterized by the deposition of extracellular protein called amyloid. There are two types of amiloidosis: primary AL and secondary AA. Renal involvement is frequent and it occasionally presents as renal failure progressive sustained by extracapillary glomerulonephritis. The rare cases reported in the literature are related to amyloidosis secondary to rheumatoid arthritis.

We report case of a 46 year old woman, smoker with autoimmune hypothyroidism, came to our observation for nephrotic syndrome, hypertension, anemia, acute renal failure. Renal biopsy showed extracapillary glomerulonephritis overlaid on primary amyloidosis AL.

Despite the early start of drug therapy, the patient died after about six months.

Very often patients with chronic kidney disease (CKD) on dialysis undergo neck ultrasonography to study parathyroid glands. Although diagnosis and treatment of secondary hyperparathyroidism (sHPT) is based on the serum levels of both the intact parathyroid hormone (iPTH) and the parameters of mineral metabolism (calcium, phosphorus), parathyroid ultrasound provides an important diagnostic tool in diagnosis, clinical follow-up, and therapeutic response of sHPT. Nevertheless there are limited data regarding the ultrasonographic evaluation of the thyroid gland, with only a few reports investigating thyroid nodules in hemodyalized patients.

In the present paper we describe the case of a 37-year old male hemodyalized patient in whom ultrasound examination of the neck revealed a solitary thyroid nodule, which turned out to be different from what was initially expected.

Diabetes mellitus is a disease with a heavy impact on social-health. About 15% of the over 200 million patients affected by diabetes in the world have lesions on the legs of various kind, among which pure ischemic, neuro-ischemic, and neuropathic lesions, or lesions caused by local infections; in addition, 50% of these patients require limb amputation. A typical characteristic of the diabetic person is the lack of the earliest symptom of peripheral arterial diseases: the “ intermittent ” claudicatio that often occurs together with sensory neuropathy and causes a decreased perception of pain. Therefore, the primary and secondary prophylaxes of the diabetic foot lesions are one of the main aims of the Health Care Program.

The present review shows the various types of advanced medications used in our facility to treat severe wounds, highlighting the fact that a multidisciplinary and multi-professional approach is essential to any Health Organization for dealing with the increasingly heavy lesions of hospitalized patients.

Thanks to a growing awareness by the healthcare professionals and the considerable improvements in the patients' lifestyle, the solution solving the current problems comes from the opening of new specialized centers for the treatment of diabetic foot lesions in hemodialysed patients by means of multi-skilled figures, among which dermatologists, vascular surgeons, diabetologists, plastic surgeons, nephrologists, and specialist nursing staff.

According to the “Hume law”, no drop of ethics can derive from a scientific rule. This law can be also applied as a guide for healthcare policy, given the limitations of secular moral reasoning. Such an approach is offered to provide the strongest case for the robust web of moral obligations in the dialysis area. It is important to inquire dialysis patients on how they wish to be treated when competent, who should make judgments on their behalf, and the circumstances under which treatment should be withdrawn. Against a plurality of visions of justice, fairness, and rights in healthcare and, in particular, in the approach to dialysis, basic moral rules of thumb can still be articulated to guide physicians, other healthcare professionals, and care-policy makers. These rules of thumb can be stated in the following issues: (i) principle of truth; (ii) principle of value and dignity of man; (iii) principle of freedom; (iv) informed consent; (v) principle of justice; (vi) bioethical models.

The association between physical exercise (fitness) and mortality is a definite certainty in the scientific literature.

Objective of this review is to analyse in depth the existing evidence of the association between fitness and tendency to develop chronic non-fatal kidney and heart events.

While it is undisputed that cardio-respiratory functional capacity is to some extent correlated to physical activity throughout life, can one postulate that a similar reasoning also applies to renal function?

The paper presents a very simple introduction to the concept of confidence interval for both a proportion and a mean. The confidence interval is useful when analyzing data that refer to a sample extracted from a target population. The confidence interval defines the upper and lower values of the interval of the variable we are studying; in other words, it defines the interval that one should expect, with a predefined level of confidence, to contain the true value of the proportion or the mean value of the population.

The new website of the Study Group on Peritoneal Dialysis (GdSDP) is characterized by the graphics, the multimedia contents, and eight subject areas. The innovations are the areas dedicated to Pediatrics, nurses, and e-learning (FAD) for obtaining CME credits. The chief editor is the coordinator of the GdSDP that relies on the contributions of the managers in the sector.

In the summer of 1797, at the age of 27 and at the time of acoustic symptoms onset, the musician got gastrointestinal typhus, with partial remission and frequent relapses in the following years. Only in October 1802 Beethoven acknowledged his deafness, accompanied by tinnitus; his acoustic disease started with the initial involvement of the left ear only, until right ear involvement and total deafness. Beethoven underwent several pharmacological treatments without any relief also due to his stubbornness and lifestyle (wine and coffee abuse). The use of acoustic devices in his left ear, due to his complete right ear deafness, did also not improve his condition. To amplify the sound intensity, the musician tried to use a wooden cover placed between the piano and the ears. In 1822, during Fidelio's tests, Beethoven could not hear anything sang by the actors. In May 1824, at the end of his exhibition, he didn't realize that all bystanders were actively clapping. In 1825, signs and symptoms of hepatic involvement appeared with hematemesis due to esophageal variceal bleeding. In 1826, his general conditions worsened and abdominal pain, diarrhea, jaundice, and ascites appeared followed by several paracentesis (removing up to 14 L of liquid). On March 27th 1827, Ludwig van Beethoven died, and 2 days later more than 20,000 people (including Franz Schubert) attended his funeral. A final characterization of Beethoven's deafness was actually not collected: otosclerosis, acoustic nerve degeneration, post-infective disease, luetic complications or Paget's disease were also postulated. Autoptic evidences suggest hepatic or kidney disease to be the cause of Beethoven's death. It has been postulated that Beethoven's imagination and creativity was greatly influenced by his deafness.

The new millennium's scenario is more complex than in the past. Patients are older and more critical than 30 years ago; therefore, I suggest a different approach: taking advantage of the new protagonists of our field to improve our practice. It becomes thus necessary a close collaboration with all relevant colleagues, among whom:

• experienced nephrologists that believe in us, in our potential, and in our preparation

• radiologists and anesthesiologists eager to pursue a continuous education

• surgeons for the decision of the kind of vascular access: arteriovenous fistula (AVF), native or prosthetic, distal or proximal.

I believe that nephrologists can create an AVF, since they have a working knowledge of AVF's use in hemodialysis patients. However, the best choice is still the complete collaboration with surgeons that are available to share their technical experience with young nephrologists. Moreover, it would be ideal to establish an effective collaboration for the preparation of prosthetic AVFs for which surgical skills are fundamental.

The general practitioner is a key referent for the diagnosis and treatment of autosomic dominant polycystic kidney disease (ADPKD), a disease not only difficult to diagnose but also characterized by specific traits that could put at risk other organs. This is why AIRP Onlus (the ADPKD Patients Association), in the occasion of the XXX SIMG National Congress, presented to the whole scientific community two volumes dedicated to this pathology, distributing them to more than 7,500 general practitioners. A very important initiative aimed at increasing the attention on the issue and supporting patients and their families. As shown by an epidemiological study conducted by Dr Salvatore Campo in the Sicily Region, it is very important that general practitioners can thoroughly know and recognize this disease in order to fully take in charge the patient.