We report the case of a 64-year-old man referred for evaluation of progressive renal dysfunction associated with hypertriglyceridemia and non-nephrotic proteinuria. There was no evidence of plasma cell dyscrasia, chronic inflammatory disease, or other secondary causes of amyloidosis. Renal biopsy revealed amyloid deposits with predominant glomerular involvement. Congo red staining confirmed the presence of amyloid, showing characteristic apple-green birefringence under polarized light. Immunohistochemical studies were non-diagnostic. Therefore, laser microdissection followed by mass spectrometry-based proteomic analysis was performed and identified apolipoprotein C-II (ApoC-II) as the main component of the amyloid deposits. Genetic analysis subsequently demonstrated a heterozygous c.122A>C (p.Lys41Thr) variant in the APOC2 gene, confirming the diagnosis of hereditary apolipoprotein C-II-related amyloidosis (AApoC-II), a very rare form of hereditary amyloidosis with predominant renal tropism.

Background. The spread of home hemodialysis is increasing in Italy and across Europe, as noted in the document ("La diffusione dell'emodialisi domiciliare sta aumentando in Italia ed in Europa"). Its main feature enabling hospital use is its portability and independence from centralized water treatment systems, thanks to the use of sterile pre-mixed dialysate bags. This allows treatments to be delivered in environments not traditionally equipped for dialysis, such as isolation rooms on inpatient wards, emergency departments, or temporary units prior to definitive intrahospital transfer. Materials and Methods. Dialysis therapy used: The NxStage VersiHD system was employed to perform hemodialysis in three clinical scenarios: 1. Non-transportable patient with anasarca and acute kidney injury. The patient, hospitalized in the pulmonology ward and receiving oxygen therapy via tracheostomy, developed acute kidney injury with anuria requiring renal replacement therapy. The NxStage VersiHD device, already available in the dialysis unit, was transported to the patient's room. Two treatments were performed using 25 L of dialysate: the first lasting 3 hours and the second 4 hours. The system was used emergently for ultrafiltration and solute clearance until spontaneous diuresis resumed, despite a logistically challenging setting. 2. Chronic hemodialysis patient presenting to the emergency department with severe dyspnea due to fluid overload and SARS-CoV-2 infection. Because timely isolation in the dialysis unit was not feasible, urgent hemodialysis was performed using the NxStage VersiHD in a day-hospital room of our department, achieving reduction of pulmonary edema. 3. A 61-year-old woman with cirrhosis presented with splenic hemorrhage and acute renal failure. Admitted to intensive care, she underwent CVVHDF for 72 hours. She was transferred to the nephrology ward, which was not transportable due to the risk of hemorrhage. The NxStage VersiHD and the necessary equipment for dialysis scheduled for the following day were transported to the ward. Conclusions. The report aims to highlight the feasibility of using a home-designed dialysis technology safely within specific intrahospital contexts, offering an alternative strategy for dialysis support when infrastructural limitations or patient immobility prevent standard approaches. Staff training on NxStage operation, emergency procedures, and complication management is essential to minimize human error. The main challenges in training hospital nursing teams for occasional NxStage use include limited operational familiarity, management of device-specific complications, and integration of safety protocols. Operational unfamiliarity arises because, although NxStage is designed to simplify setup through preassembled cartridges and sterile dialysate bags, it differs technically from conventional dialysis systems. Lack of routine use is the primary reason for failure of NxStage implementation projects in hospital settings. To address this issue, our center adopted continuous use of NxStage in the dialysis unit for selected patients, ensuring regular machine operation. To avoid inadequate clearance with a thrice weekly schedule, 4 hour sessions were performed in patients with a distribution volume compatible with achieving a weekly Kt/V of 2.2, in accordance with international guidelines.

Throughout the natural history of chronic kidney disease (CKD), most patients experience fatal or non-fatal cardiovascular events. In this review, we address the role of low-density lipoprotein cholesterol (LDL-C) in the excess cardiovascular risk associated with CKD and examine the impact of both traditional and novel LDL-C-lowering therapies across the entire spectrum of CKD. Current guidelines for the prevention of atherosclerotic cardiovascular disease (ASCVD), developed by European and US cardiology societies, recommend assessment of overall cardiovascular risk to tailor the intensity of preventive strategies to the individual patient's risk profile: the higher the cardiovascular risk, the more intensive the intervention should be. Novel therapies have demonstrated efficacy in achieving lower LDL-C targets, which are often unattainable with conventional treatment. The identification of vulnerable coronary plaques, rather than the mere presence of vascular lumen narrowing, represents a promising imaging target for guiding intensified preventive strategies in high-risk populations, including patients with CKD. In CKD, cardiovascular risk progressively increases as kidney function declines. Despite clear recommendations from both nephrology and non-nephrology guidelines, initiation, maintenance, and intensification of lipid-lowering treatment, as well as achievement of LDL-C targets, remain suboptimal in the CKD population. As novel lipid-lowering therapies provide additional therapeutic options for patients with CKD, there is now a compelling need to increase awareness of cardiovascular risk and integrate lipid management into the broader, longitudinal care of patients with CKD across all stages of the disease.

Renal rehabilitation is increasingly recognized as a complementary strategy to address the clinical and functional complications of maintenance hemodialysis. This review evaluated the effects of renal rehabilitation, including structured exercise, nutritional support, and multidisciplinary interventions, on anemia, nutritional status, and activities of daily living in adults undergoing maintenance hemodialysis. Studies published between 2015 and 2025 were reviewed according to PRISMA criteria, and 42 studies were included in the qualitative synthesis. Overall, renal rehabilitation was associated with modest improvements in hemoglobin levels and erythropoiesis-stimulating agent responsiveness, as well as favorable changes in nutritional and muscle-related parameters. The most consistent benefits were observed in functional outcomes, including exercise capacity, muscle strength, frailty, and activities of daily living. These findings support renal rehabilitation as a promising multidimensional approach in maintenance hemodialysis, although heterogeneity among interventions and study designs highlights the need for standardized, adequately powered long-term trials.

Ultrasound is nowadays widely used in nephrological practice as a first-line clinical tool. Despite this widespread adoption of the technique, the medico-legal aspects of ultrasound reporting have so far received limited attention, even though the report represents the formal completion of the medical act and the only document endowed with probative value. In the legal context, in fact, the ultrasound examination can be assessed exclusively through what is documented in the report, regardless of the technical quality of the examination itself. The present paper analyzes the main medico-legal aspects of ultrasound reporting, with particular reference to the activity of the nephrologist, focusing on the essential requirements of the report, the most common critical issues with medico-legal relevance, and the implications in terms of professional liability. The role of declaring the limitations of the examination and of structured reporting as possible tools for clinical risk management and professional protection will also be examined.

Background. The aging healthcare workforce in Italy, with an average age approaching 50 years, creates demographic imbalances that hinder intergenerational collaboration and knowledge transfer. This issue is particularly critical in nephrology, where nurses play a pivotal role in delivering personalized care by combining advanced technical expertise with high-quality human support. This study aims to evaluate and compare the generational characteristics of Italian nurses working in the nephrology field. Methods. A cross-sectional study based on the Multidimensional Nursing Generations Questionnaire (MNGQ), administered between February 2023 and February 2024 to nurses working in the nephrology field. Findings. The study involved 520 Italian nurses working in the nephrology field. The analysis revealed significant generational differences. Millennials exhibited the highest levels of intergenerational conflict (p < 0,001) and greater adaptability to change (p < 0,001), while Baby Boomers reported higher scores in patient safety perspectives (p = 0,003). Younger generations (Millennials and Generation X) demonstrated a greater work propensity compared to Baby Boomers (p < 0,001). No significant differences were observed in teamwork (p = 0,199). Conclusion. The study highlights how generational differences impact the nursing profession in Italy, particularly in nephrology, where academic and practical skills coexist. To harmonize these competencies, institutions should promote mentorship programs and collaborative training, fostering inclusive work environments that enhance teamwork and care quality while addressing the evolving challenges of the healthcare system.

Background. Cardiovascular-kidney-metabolic (CKM) syndrome encompasses obesity, type 2 diabetes, cardiovascular disease, and chronic kidney disease. Insulin resistance has traditionally been considered the primary driver, with hyperinsulinemia viewed as a compensatory response. However, emerging evidence suggests that hyperinsulinemia may precede insulin resistance in specific phenotypes and contribute to early disease mechanisms. Methods. We conducted a narrative review of the role of hyperinsulinemia in CKM syndrome. Literature searches were performed in PubMed/MEDLINE, Embase, and Scopus through December 2025. We prioritised prospective cohort studies, meta-analyses, Mendelian randomisation studies, and randomised controlled trials, and synthesised evidence across cardiovascular, renal, and metabolic domains. Results. Sustained hyperinsulinemia is associated with myocardial hypertrophy and fibrosis through selective preservation of mitogenic signalling, contributing to heart failure phenotypes. In the kidney, it enhances sodium and glucose reabsorption, increases intraglomerular pressure, and promotes podocyte dysfunction, potentially accelerating CKD progression. Epidemiological evidence consistently shows associations between elevated fasting insulin levels and cardiovascular events, renal outcomes, and mortality across diverse populations, with meta-analytic estimates reporting a pooled relative risk of 1.46 (95% CI 1.16-1.84) for incident cardiovascular events. However, available data are largely observational and heterogeneous in exposure definitions and adjustment models. Conclusions. Hyperinsulinemia represents a clinically relevant and potentially modifiable component of CKM syndrome, with effects extending beyond glucose homeostasis. While causality is biologically plausible and supported by genetic and epidemiological evidence, it remains to be established through interventional studies. Recognition of hyperinsulinemia may support earlier risk stratification and mechanism-based interventions, although prospective validation is required before routine clinical implementation.

Background. Renal biopsy is widely performed worldwide, but reported bleeding risks vary due to differences in technique, devices, operators, and patient populations. This study aimed to define the bleeding risk associated with current spring-loaded biopsy guns in a South-Asian population, identify relevant risk factors, and quantify the additional cost and hospital stay from bleeding complications. Methodology. In this six-month prospective observational cohort study, all adult patients undergoing kidney biopsy at a tertiary hospital were enrolled. Demographic, clinical, radiological, procedural, and histopathological data were collected. Bleeding was defined as gross haematuria, perinephric hematoma, hemoglobin drop, transfusion requirement, or need for intervention. Factors associated with bleeding were evaluated using univariate analysis and multivariate logistic regression. Results. Among 980 patients, overall bleeding incidence was 4.9%, with 1.6% clinically significant events. On univariate analysis, higher creatinine, urea, dialysis dependence, and ischemic heart disease were associated with bleeding, whereas diabetes mellitus was associated with lower bleeding risk. On multivariate analysis, ischemic heart disease remained independently associated with bleeding, while diabetes mellitus remained associated with lower bleeding risk. Histopathological chronicity, including glomerulosclerosis and interstitial fibrosis, was also associated with clinically significant bleeding events (requiring transfusion or intervention). Conclusions. Bleeding after kidney biopsy was infrequent in this cohort. Ischemic heart disease and histopathological chronicity were associated with increased bleeding risk, while procedural and operator-related factors were not significantly associated in this cohort, although these findings should be interpreted cautiously. Bleeding was associated with increased hospital stay and healthcare costs.

Introduction. In Africa, particularly in Senegal, sarcopenia among patients undergoing hemodialysis remains insufficiently studied. In this context, we conducted this study with the objective of describing the epidemiological and etiological aspects of sarcopenia among hemodialysis patients in Dakar in 2025. Patients and Methods. We carried out a multicenter, cross-sectional, descriptive and analytical study over a 15-day period in four hemodialysis centers in Dakar. Sarcopenia was diagnosed according to the diagnostic criteria of the EWGSOP2 working group. Cluster sampling of hemodialysis centers was performed, followed by stratified sampling by dividing patients into two groups: younger patients (< 65 years) and older patients (≥ 65 years). All patients on chronic hemodialysis for at least three months were included. Results. A total of 152 patients were included. The mean age was 47.88 ± 13.68 years. There were 77 men (50.7%) and 75 women (49.3%), with a sex ratio of 1.02. The mean body mass index (BMI) was 20.72 ± 4.91 kg/m[2] (range: 12.65-38.39), and 23.7% of patients had a BMI < 18.5 kg/m[2]. The mean serum ferritin level was 829.73 ± 778.4 ng/mL. Based on the SARC-F questionnaire, sarcopenia was suspected in 55 patients. Handgrip strength was reduced in 82 patients (53.94%), including 38 men and 44 women. Bioelectrical impedance analysis confirmed sarcopenia in 64 patients, yielding a prevalence of 42.10%. Thirty patients presented with severe sarcopenia. In multivariate analysis, factors independently associated with sarcopenia were male sex (OR = 5.98; 95% CI: 2.27-15.74), undernutrition (BMI < 18.5) (OR = 6.25; 95% CI: 2.08-18.74), and overweight (BMI > 25) (OR = 0.06; 95% CI: 0.01-0.49). Conclusion. Sarcopenia is common among hemodialysis patients in Dakar. Male sex, and undernutrition are significant risk factors. A prospective cohort study would be relevant to better assess its prevalence, risk factors, and prognostic impact.

Objective. To evaluate the acute cross-shift changes in renal function and occupational risk factors associated with environmental nephropathy among rural workers in the Colombian Caribbean. Material and Method. An observational, cross-sectional analytical study was conducted with a community-based sample of 78 active rural workers (48 agricultural and 30 construction workers). Variables analyzed included sociodemographic characteristics, toxic habits, agrochemical exposure, fluid intake, and clinical parameters. Blood and urine samples were collected pre- and post-shift. A multivariable linear regression model was constructed to identify independent predictors of the acute cross-shift decline in estimated glomerular filtration rate (ΔeGFR). Results. The cohort was highly exposed to adverse occupational conditions, including prolonged workdays (69% worked > 48 hours per week) and insufficient hydration (79% consumed < 3 liters of fluid daily). Post-shift analysis revealed significant acute physiological stress, including a significant decline in overall eGFR (p < 0.001) and acute increases in urinary specific gravity, incident proteinuria (p=0.008), and leukocyturia (p<0.001). Notably, incident hematuria increased significantly across the workday exclusively among agricultural workers (21% to 40%, p = 0.02). Multivariable analysis identified occupational exposure to herbicides (β = -16, p = 0.014) and active smoking status (β = -12, p = 0.016) as the strongest independent predictors of acute cross-shift renal function loss. Conclusion. Workers under adverse environmental conditions in the Colombian Caribbean experience severe acute cross-shift declines in renal function and markers of acute tubular injury, driven by heavy labor, heat stress, and herbicide exposure.

Peritoneal dialysis has shown to reduce days of hospitalization, NYHA functional class and to improve slightly left ventricular ejection fraction in heart failure patients. For the first time, the nationwide 2024 Census of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology is able to analyze and to compare heart failure patients treated by peritoneal dialysis to a time matched cohort of chronic kidney disease patients under peritoneal dialysis. The census data of 170 Italian dialysis centers are presented. 1063 patients started peritoneal dialysis for kidney disease whereas 47 patients for heart failure, resulting in a prevalence of 3371 kidney disease patients and 72 heart failure patients in 2024. Heart failure patients presented higher age and male prevalence. CAPD was mainly used as dialysis start modality in heart failure patients (78.7%) with incremental dialysis prescription more often applied and assisted dialysis more often needed. Mean duration of peritoneal dialysis was 31.3 months in kidney disease patients, whereas 17.6 months in heart failure patients, mainly due to a 4-fold increased risk of death. The peritonitis risk was lower in heart failure patients with 0.097 episodes / patient-year compared to 0.166 episodes / patient-year in kidney disease patients. The census results confirm that peritoneal dialysis for heart failure is a feasible time-limited therapeutic opportunity for a known high-risk population of mostly elderly, male and frail patients requiring assisted dialysis.

Assisted peritoneal dialysis (PD) is an important option for frail patients with advanced age, comorbidities, and reduced autonomy who face barriers to self-managed home dialysis. This study evaluates the current use of assisted PD in Italy using data from the 2024 Italian Peritoneal Dialysis Census and compares findings with previous surveys conducted since 2008. Data were collected from 228 dialysis centers, with 221 centers providing information on assisted PD, covering 4,229 prevalent PD patients. Assisted PD was reported in 904 patients (21.4%). Family members were the main caregivers (86.2%), followed by paid caregivers (8.1%), institutional staff (2.9%), and nursing home personnel (2.8%). Over time, the proportion of assisted PD remained stable between 21% and 25%, with no significant change in caregiver distribution. Centers applying assisted PD were larger, had higher PD prevalence, and managed more PD patients compared with centers not using assisted PD. Geographic variability was observed, with the highest prevalence in island regions. Only a small proportion of patients in nursing homes were treated with PD compared to hemodialysis, highlighting organizational and staffing barriers. These findings show that assisted PD in Italy has remained stable over the past two decades and is predominantly based on family caregiving, unlike Northern European countries where professional home care predominates. The limited use of institutional and nursing home support suggests unmet needs and potential areas for improvement. Economic incentives, regional support programs, and telemedicine may help expand assisted PD access and promote home-based dialysis in frail populations.

Introduction. Incremental peritoneal dialysis (Incr-PD) is a strategy to start PD when residual renal function is preserved. Methods. We describe the Incr-PD practice across the last 20 years based on the 9th Italian PD Census utilizing a standardized definition of Incr-PD for both CAPD and APD (≤2 exchanges/day, ≤4 sessions/week). Results. In 2024, 1398 patients started PD, 40.2% on Incr-PD. 73.8% of the dialysis centers used Incr-PD. Incr-PD increased from 11.9% in 2010 to 40.2 % in 2024. This is due to both the increase in the number of centers which started to use it (29.2% in 2005 to 73.8% in 2024), and in the number of patients treated with this modality in centers already confident with this modality (33.4% in 2005 vs 50.9% in 2024). Most of Incr-PD patients started with CAPD (84.5%) while APD was the preferred modality when full-PD is prescribed as first PD modality (64.7%). Regarding incremental CAPD, 62.5% of physicians start with one exchange, while 37.4% use two. In the latter case, only 26.2% prescribe two continuous exchanges with "the abdomen always full". Incr-PD centers have higher incidence (21.7% vs 15.1%, p < 0.01) and prevalence (16.9% vs 12%, p < 0.01) of PD patients compared with those not using it. Conclusions. The trend confirms the success of Incr-PD, mostly in the form of CAPD. The increased Nephrologist's confidence with Incr-PD allowed the expansion of this PD modality which is the mainstay of dialysis personalization.