Sesto San Giovanni, Italy
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Ponticelli C.,Nephrology and Dialysis Unit | Sala G.,Nephrology and Dialysis Unit | Glassock R.J.,University of California at Los Angeles
Mayo Clinic Proceedings | Year: 2015

With advancing age, the functional reserve of many organs tends to decrease. In particular, the lean body mass, the levels of serum albumin, the blood flow to the liver, and the glomerular filtration rate are reduced in elderly individuals and can be further impaired by the concomitant presence of acute or chronic kidney disease. Moreover, patients with kidney disease are often affected by comorbid processes and are prescribed multiple medications. The aging process also modifies some drug interactions, including the affinity of some drugs for their receptor, the number of receptors, and the cell responses upon receptor activation. Therefore, older patients with kidney disease are particularly susceptible to the risks of adverse drug reactions. Planning a pharmacological regimen in such patients is confounded by the paucity of information available on the pharmacokinetic and pharmacodynamic profiles of a large number of drugs commonly used in this group of patients. Finally, many aged patients suffer from unintentional poor compliance. In this review, the problems physicians face in designing safe and effective medication management in elderly individuals are discussed, paying attention to those more frequently used, which may be potentially harmful in patients with kidney disease. The risks of overdosing and underdosing are outlined, and some recommendations to reduce the risk of adverse drug reactions are provided. A review of the literature covering the field of drug management in older patients with kidney disease was performed by selecting those articles published between January 1, 1990, and December 1, 2014, using PubMed as a search engine with the keywords elderly, kidney disease, drugs, drug interaction, and renal function. © 2015 Mayo Foundation for Medical Education and Research.


Rostoker G.,Nephrology and Dialysis Unit | Cohen Y.,Hopital Prive Claude Galien
Journal of Computer Assisted Tomography | Year: 2014

During the past 2 decades, routine use of recombinant erythropoiesis-stimulating agents (ESAs) has enabled anemia to be corrected in dialysis patients, thereby improving their quality of life and permitting better outcomes. As successful use of ESA requires sufficient available iron, almost all end-stage renal disease patients on ESA now receive concomitant parenteral iron therapy. Radiologists must be aware that iron overload among dialysis patients is now an increasingly recognized clinical situation in the ESA era yet was previously considered rare. The KDIGO Controversies Conference on Iron Management in Chronic Kidney Disease, which took place in San Francisco on March 27 to 30, 2014, recognized the entity of iron overload in hemodialysis patients and called for an agenda of research on this topic, especially by means of magnetic resonance imaging (MRI). It is therefore very likely that radiologists will be heavily solicited in the future by nephrology teams requesting quantitative hepatic MRI in dialysis patients, both for research purposes and for diagnosis and follow-up of iron overload. Radiologists should be aware of the marked differences in the pharmacological properties of available intravenous iron products and their potential interference with MRI. Specific MRI protocols need to be established in radiology divisions for each pharmaceutical iron product, especially for treated dialysis patients. © 2014 Lippincott Williams & Wilkins.


Emma F.,Bambino Gesu Childrens Hospital and Research Institute | Bertini E.,Bambino Gesu Childrens Hospital and Research Institute | Salviati L.,University of Padua | Montini G.,Nephrology and Dialysis Unit
Pediatric Nephrology | Year: 2012

Mitochondrial cytopathies constitute a group of rare diseases that are characterized by their frequent multisystemic involvement, extreme variability of phenotype and complex genetics. In children, renal involvement is frequent and probably underestimated. The most frequent renal symptom is a tubular defect that, in most severe forms, corresponds to a complete De Toni-Debré- Fanconi syndrome. Incomplete proximal tubular defects and other tubular diseases have also been reported. In rare cases, patients present with chronic tubulo-interstitial nephritis or cystic renal diseases. Finally, a group of patients develop primarily a glomerular disease. These patients correspond to sporadic case reports or can be classified into two major defects, namely 3243 A>G tRNA LEU mutations and coenzyme Q10 biosynthesis defects. The latter group is particularly important because it represents the only treatable renal mitochondrial defect. In this Educational Review, the principal characteristics of these diseases and the main diagnostic approaches are summarized. © IPNA 2011.


Fusaro M.,CNR Institute of Neuroscience | Gallieni M.,Nephrology and Dialysis Unit | Jamal S.A.,University of Toronto
Kidney International | Year: 2014

Bone fractures in dialysis patients have been poorly studied in the past. Tentori et al. partially fill this gap, assessing the incidence of post-fracture morbidity and mortality in patients of the Dialysis Outcomes and Practice Patterns Study (DOPPS). A high frequency of fractures and increased adverse outcomes following a fracture were observed. The nephrology community should pay more attention to bone fractures in dialysis patients © 2013 International Society of Nephrology.


Toffolo A.,Hospital of Oderzo | Ammenti A.,Gemini Medicina Specialistica | Montini G.,Nephrology and Dialysis Unit
Acta Paediatrica, International Journal of Paediatrics | Year: 2012

Kidney scarring related to urinary tract infection in childhood has been considered the cause of serious long-term clinical consequences. This assumption is now debated, as the advent of routine antenatal ultrasound in the 1980s has shown that a consistent part of the changes previously attributed to postinfectious scarring is mainly due to congenital malformations. With the aim of determining what is presently known on the long-term clinical consequences of urinary tract infections (UTIs) in childhood, we performed a review of the literature on the relation between UTIs and blood pressure, renal function, growth and pregnancy-related complications. By searching Medline/PubMed and Embase from 1980 to 2011, we identified 20 cohorts of children from 23 papers. Conclusions: Renal function: there are no clear data to establish long-term consequences following UTIs during childhood. Most data seem to show that the outcome of renal function can already be delineated at first presentation or in the initial years of follow-up; only 0.4% of children with normal renal function at start presented a decrease during follow-up. Hypertension: there is a low risk, associated with renal damage. Growth and pregnancy-related complications: the few available data seem to exclude a major influence of UTIs. © 2012 Foundation Acta Pædiatrica.


Gallieni M.,Nephrology and Dialysis Unit | Fusaro M.,National Research Council Italy
Kidney International | Year: 2014

The vitamin K-dependent proteins (VKDPs) matrix Gla protein and osteocalcin protect from cardiovascular calcifications and bone fractures. A vitamin K recycling system maintains sufficient vitamin K levels for activation of VKDPs through γ-glutamyl carboxylase (GGCX). Kaesler et al. demonstrate that uremia per se can interfere with GGCX activity, contributing to vitamin K deficiency in chronic kidney disease and opening the path to the clinical use of vitamin K, currently tested in randomized trials. © 2014 International Society of Nephrology.


Cucchiari D.,Nephrology and Dialysis Unit
Nephron | Year: 2016

For a long time now, kidney transplant rejection has been considered the consequence of either cellular or antibody-mediated reaction as a part of adaptive immunity response. The role of innate immunity, on the other hand, had been unclear for many years and was thought to be only ancillary. There is now consistent evidence that innate immune response is a condition necessary to activate the machinery of rejection. In this setting, the communication between antigen-presenting cells and T lymphocytes is of major importance. Indeed, T cells are unable to cause rejection if innate immunity is not activated. This field is currently being explored and several experiments in animal models have proved that blocking innate immunity activation can promote tolerance of the graft instead of rejection. The aim of this review is to systematically describe all the steps of innate immunity response in kidney transplant rejection, from antigen recognition to T-cells activation, with a focus on clinical consequences and possible future perspectives. © 2016 S. Karger AG, Basel Copyright © 2016, S. Karger AG. All rights reserved.


Ponticelli C.E.,Nephrology and Dialysis Unit
Kidney International | Year: 2015

Cold ischemia triggers a cascade of noxious effects, which are amplified by restoration of blood supply reperfusion. These injuries generate inflammatory and immune responses that may potentially result in delayed graft function, enhanced alloimmune reactivity, and development of progressive pathological changes. Debout et al. outline the clinical importance of cold ischemia time in renal transplantation by demonstrating that each additional hour of cold ischemia can increase the risk of allograft failure and death. © 2014 International Society of Nephrology.


Santoro A.,Dialysis and Hypertension Azienda Ospedaliero Universitaria di Bologna | Mandreoli M.,Nephrology and Dialysis Unit
Kidney and Blood Pressure Research | Year: 2014

The pathogenesis of cardiovascular disease in CKD differs subtly from that of non-CKD patients. As renal function declines, the role and impact of treating classical risk factors may change and diminish. However, hypertension, hypercholesterolaemia and smoking cessation management should be optimized and may require multiple agents and approaches, particularly as CKD advances. Hypertension treatment would appear to be one management area in which performance is less than ideal. Moreover there are mechanisms and risk factors that are specific to CKD, capable of triggering a vascular pathology and that justify the surplus of CV morbidity in CKD patients and that require we consider CKD as a CV risk factor per se. In the initial stages of CKD it would be advisable to implement all the preventative measures to stem the onset of CV disease, whereas in the more advanced stages a multifactorial approach is likely to be necessary, as we have learned from the STENO-study within the diabetes. © 2014 S. Karger AG, Basel.


Ponticelli C.,Nephrology and Dialysis Unit | Sala G.,Nephrology and Dialysis Unit
Expert Review of Clinical Immunology | Year: 2014

Vitamin D is a hormone with pleiotropic effects. It mainly regulates calcium and phosphate metabolism through interactions with FGF23 and its receptor klotho. In addition, it has been shown that Vitamin D also regulates the immune response and has protective effects from cardiovascular disease, cancer and infections. Most renal transplant recipients have overt Vitamin D deficiency, a condition that may be associated with a decline in graft function and other complications. After kidney transplantation, elevated levels of FGF23 may predict increased risks of death and allograft loss. Theoretically, an optimal Vitamin D supplementation might favor operational tolerance and protect transplant recipients from the triad cardiovascular disease-cancer-infection. However, more solid data are needed to confirm this and to set the optimal level of serum Vitamin D supplementation in order to attain the best clinical outcome. © 2014 Informa UK, Ltd.

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