[Diuretic therapy in patients with congestive heart failure: an update].

Heart failure is one of the major causes of hospitalization in Italy and the Western world and is characterized by different pathophysiological conditions and multiple precipitating factors. The state of congestion, which is the main clinical presentation on admission, is treated in the majority of cases with diuretic therapy until hemodynamics are normalized and symptoms resolved. Treatment with loop diuretics, although widely used in the treatment of chronic heart failure, may result in diuretic resistance, electrolyte and volemic imbalance, neurohormonal activation, and worsening renal function.

Age- and sex-tailored serum phosphate thresholds do not improve cardiovascular risk estimation in CKD.

Background: Disordered metabolism of phosphorus is one of the hallmarks of chronic kidney disease (CKD), resulting in increased cardiovascular morbidity and mortality. Age and sex may affect the metabolism of phosphorus and subsequently its serum level. We evaluated if age- and sex-specific cutoffs for hyperphosphatemia may define cardiovascular risk better than the current guideline cutoffs.

Metabolic and toxicological considerations for diuretic therapy in patients with acute heart failure.

Introduction: Diuretics are widely recommended in patients with acute heart failure (AHF). However, loop diuretics predispose patients to electrolyte imbalance and hypovolemia, which in turn leads to neurohormonal activation and worsening renal function (WRF). Unfortunately, despite their widespread use, limited data from randomized clinical trials are available to guide clinicians with the appropriate management of this diuretic therapy.

Cadmium exposure and kidney stone formation in the general population--an analysis of the National Health and Nutrition Examination Survey III data.

Background And Purpose: Cadmium exposure has been associated with a greater risk of kidney stone formation in occupational exposure studies, but data on such an association in the general population are scarce.

Subjects And Methods: We assessed the National Health and Nutrition Examination Survey data from 1988 to 1994 in terms of the risk of stone formation. Persons reporting a history of kidney stones were defined as stone formers (n=749), and the association between a positive history of kidney stones and high environmental cadmium exposure levels (defined as urinary cadmium >1 μg/g) was analyzed by logistic regression analysis, stratifying by sex and adjusting for age, race/ethnicity, body mass index, smoking habits, region of residence, and daily intake of calcium and sodium.

North East Italian Prospective Hospital Renal Outcome Survey on Acute Kidney Injury (NEiPHROS-AKI): targeting the problem with the RIFLE Criteria.

Acute kidney injury (AKI) in the intensive care unit (ICU) is associated with an enhanced mortality. The Acute Dialysis Quality Initiative group has proposed the RIFLE (Risk-Injury-Failure-Loss-ESRD) classification to standardize the approach to AKI. This study was performed to estimate the AKI incidence in ICU patients in northeastern Italy and describe clinical characteristics and outcomes of patients with AKI on the basis of their RIFLE class.

Disinfection of dialysis monitors.

In recent years the concept of biocompatibility is not limited to the dialytic membranes, but has been substituted by a more general viewpoint where all the parameters of the dialytic treatment are taken into consideration: the interaction of blood-surfaces (the dialyzer in all its components and the hematic lines), the sterilization of all materials, the quality of the solutions utilized for dialysis and reinfusion. Numerous studies have shown that the inflammatory response in dialysis is the cause of many of the side effects of dialytic treatment itself both acute and chronic. Hypoxemia, 'first use' syndrome, hypotension, allergic-anaphylactic reactions (short-term side effects); microinflammation, malnutrition, accelerated arteriosclerosis, anemia, beta2 microglobulin amyloidosis, immunodeficiency, bone mass loss (long-term side effects), have all been reported.

Flow distribution analysis by helical scanning in polysulfone hemodialyzers: effects of fiber structure and design on flow patterns and solute clearances.

The efficiency of a hemodialyzer is largely dependent on its ability to facilitate diffusion, as this is the main mechanism by which small solutes are removed. The diffusion process can be impaired if there is a mismatch between blood and dialysate flow distribution in the dialyzer. The objective of the paper was to study the impact of different fiber bundle configurations on blood and dialysate flow distribution and urea clearances.

Protective effect of urate oxidase on uric acid induced-monocyte apoptosis.

Uremic patients have a higher risk of infection and malignancy than normal subjects. Previous studies have deomonstrated that monocytes isolated from uremic patients display an increased apoptosis rate compared to normal subjects; furthermore uremic plasma can increase apoptosis rates on U937, a human monocytic cell line. In several pathological conditions, precipitation of uric acid crystals can lead to renal insufficiency or acute renal failure by different mechanisms.

Pulse high-volume hemofiltration in critically ill patients: a new approach for patients with septic shock.

Mortality rates in septic shock remain unacceptably high despite advances in our understanding of the syndrome and its treatment. Humoral factors are increasingly recognized to participate in the pathogenesis of septic shock, giving a biological rationale to therapies that might remove varied and potentially dangerous humoral mediators. While plasma water exchange in the form of hemofiltration can remove circulating cytokines in septic patients, the procedure, as routinely performed, does not have a substantial impact on their plasma levels.

Oxidant and carbonyl stress-related apoptosis in end-stage kidney disease: impact of membrane flux.

Apoptosis is a highly regulated process which mostly affects cell-mediated immunity. In this open-label, randomized, prospective clinical study, we determined the impact in 10 hemodialysis patients treated with high-, medium-, and low-flux membranes on spontaneous or plasma-induced apoptosis, on monocytes, as well as on oxidant and carbonyl stress. High- and medium-flux membranes significantly reduced patients' plasma-dependent proapoptotic activity on U937 monocytic cell lines.

Practice patterns in the management of acute renal failure in the critically ill patient: an international survey.

Background: Several controversies have developed over acute renal failure (ARF) definition and treatment: which approach to patient care is most desirable and which form of renal replacement therapy (RRT) should be applied is an everyday matter of debate. There is also disagreement on clinical practice for RRT including the best timing to start, vascular access, anti-coagulation, membranes, equipment and finally, if continuous or intermittent techniques should be preferred. In this lack of harmony, the epidemiology of ARF has recently displayed an outbreak of cases in the intensive care units and nephrologists and intensivists are now called to work together in the case of such a syndrome.

A new machine for continuous renal replacement therapy: from development to clinical testing.

A new continuous renal replacement therapy machine has been designed to fulfill the expectations of nephrologists and intensivists operating in the common ground of critical care nephrology. The new equipment is called Prismaflex and it is the natural evolution of the PRISMA machine that has been utilized worldwide for continuous renal replacement therapy in the last 10 years. The authors performed a preliminary alpha-trial to establish the usability, flexibility and reliability of the new device.

In vivo validation of the adequacy calculator for continuous renal replacement therapies.

Introduction: The study was conducted to validate in vivo the Adequacy Calculator, a Microsoft Excel-based program, designed to assess the prescription and delivery of renal replacement therapy in the critical care setting.

Methods: The design was a prospective cohort study, set in two intensive care units of teaching hospitals. The participants were 30 consecutive critically ill patients with acute renal failure treated with 106 continuous renal replacement therapies (CRRT).

Uremic toxins: a new focus on an old subject.

The uremic syndrome is characterized by an accumulation of uremic toxins due to inadequate kidney function. The European Uremic Toxin (EUTox) Work Group has listed 90 compounds considered to be uremic toxins. Sixty-eight have a molecular weight less than 500 Da, 12 exceed 12,000 Da, and 10 have a molecular weight between 500 and 12,000 Da.

Phosphate kinetics during different dialysis modalities.

Background: An abnormal serum phosphate concentration is common in acute renal failure patients, with a reported incidence of 65-80%. Phosphate removal and kinetics during intermittent hemodialysis (IHD) have been investigated, but there is no information on its kinetics during slow low-efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT).

Methods: Eight IHD, 8 SLED, and 10 continuous venovenous hemofiltration (CVVH) patients with a residual renal clearance of <4.

Effect of daily hemodialysis on monocytes apoptosis.

Uremia is associated with a state of immune dysfunction with increased susceptibility to infection and malignancy possibly related to dysregulation of immune system cell apoptosis. Peritoneal dialysis can restore plasma apoptosis activity on monocytes compared to intermittent hemodialysis. Whether the continuous modality or diverse clearance mechanisms involved are responsible is unknown.

Rasburicase therapy in acute hyperuricemia and renal dysfunction.

Neoplastic disorders may be complicated by acute renal failure (ARF). Different tumors may cause ARF: solid tumors involving the kidney, solid tumors not of hematological origin and not primarily involving the kidney or, more frequently, rapidly developing hematological tumors. The pathogenesis of ARF is different depending on the type of cancer, but the most frequent clinical feature is the acute tumor lysis syndrome, characterized by hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia and acute, frequently oliguric, ARF.

Renal replacement therapy in acute renal failure.

Acute renal failure (ARF) is a common condition in hospitalized patients. The aetiology and physiological characteristics differ from those of chronic renal failure (CRF) and both conditions should be approached differently. At present, the approach to the management of ARF is very heterogeneous.

Extracorporeal therapies in non-renal disease: treatment of sepsis and the peak concentration hypothesis.

In the setting of intensive care, patients with acute renal failure often present a clinical picture of the systemic inflammatory response syndrome (SIRS). SIRS can be caused by bacterial stimuli or by non-microbiological stimuli that induce a significant inflammatory response. When this response is exaggerated, the patient experiences multiple organ system failure and a condition of sepsis also defined as a systemic malignant inflammation.

Monocyte apoptosis in uremia is normalized with continuous blood purification modalities.

Uremia is associated with a state of immune dysfunction. Dysregulation of homeostasis may be directly related to abnormal apoptosis regulation in uremia, which is crucial for the maintenance of the biological system. We demonstrated that plasma from three groups of uremic subjects, i.

Longitudinal study of apoptosis in chronic uremic patients.

Uremia is associated with a state of immune dysfunction, increasing infection and malignancy rates. Dysregulation of homeostasis may be directly related to abnormal apoptosis regulation, a process which is crucial for the maintenance of the biologic system. Abnormal apoptosis rates (ARs) have been reported in the literature.