Within a dialysis cohort spread over adjacent regions of three countries, LR has the same global distribution pattern, indicating that different health and social security systems do not play a major role in inducing or preventing this practice. The contributing factors for LR that were identified are the type of the referring physician and the structure of the dialysis unit. Both factors are potential targets for an educational and collaborative approach.

The term stuck catheter refers to the condition in which a catheter is not removable from a central vein using standard techniques. Although it is a rare complication, in the last few years it has been reported ever more frequently in hemodialysis due to the widespread use of tunneled catheters. Poor knowledge of the correct procedures and limited experience and training of the specialist in facing this problem are the main reasons for catheter internalization. Stuck catheter is often diagnosed by the nephrologist who should be competent enough to manage this clinical complication. Among the many options for removing a stuck catheter from the fibrin sleeve, an interventional radiology approach, mainly with endoluminal balloon dilatation, probably provides the best solution. Vascular surgery should be reserved to selected cases in which percutaneous techniques have failed. Nephrologists must play a central role in organizing the treatment of this complication with other specialists in order to avoid making mistakes that may preclude future positive results.

Background Acute renal infarction is a rare condition whose diagnosis is often delayed. Major risk factors include atrial fibrillation, valvular or ischemic heart disease, renal artery thrombosis/dissection and coagulopathy. MethodsWe reviewed the medical records of 18 patients admitted to our Nephrology Department between 1999 and 2015 for acute renal infarction diagnosed by computed tomography. Tc-99m dimercaptosuccinic acid (DMSA) scintigraphy was performed in some patients during follow-up to assess parenchymal lesions and estimate differential kidney function. ResultsMean age was 59.8 years. Major associated risk factors included hypertension (44 %), obesity (33 %), atrial fibrillation (28 %), peripheral vascular disease (17 %), smoking (17 %), prior thromboembolic event (11 %), diabetes (11 %), estroprogestinic therapy (11 %). Seventy-two percent of patients presented with flank pain. Mean serum creatinine was 1.2 ± 0.6 mg/dl. Acute kidney injury occurred as the initial manifestation in two patients. Patients were managed conservatively, with low molecular weight heparin (83 %) or aspirin (11 %). At the end of follow-up serum creatinine was 1.1 ± 0.3 mg/dl; one patient remained on chronic hemodialysis. 58 % of patients who underwent renal scintigraphy after a median of 8 months had a reduced contribution of the previously affected kidney to total renal function. ConclusionRisk factors associated with the development of chronic kidney disease following renal infarction are unknown. In our subjects, renal function remained stable in all but one patient who developed end stage renal disease. Further studies should focus on etiology and evolution of kidney function in patients with acute renal infarction. IntroductionAcute renal infarction, due to an abrupt interruption of renal arterial flow, is a rare condition with an estimated incidence of 0.004-0.007 % in the Emergency Department setting [1,2]. Non-specific clinical presentation mimicking other pathologic states (e.g. urolithiasis, acute pyelonephritis, other acute abdominal diseases) often causes a delay in the diagnosis, which may increase the risk of impaired renal failure [3][4][5]. Radiologic diagnosis of renal infarction is based on enhanced contrast computed tomography (CT), which typically indicates the presence of a wedge-shaped hypodense area in the peripheral region [2]. Major risk factors for renal infarction include atrial fibrillation, valvular or ischemic heart disease, renal artery thrombosis/dissection and coagulopathy. Etiology remains unknown in many cases [4,6,7]. We describe the clinical and radiological characteristics and renal prognosis of 18 patients with acute renal infarction.

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Cardiovascular disease (CVD) remains the major cause of death in patients with end-stage renal disease (ESRD). Traditional risk factors do not explain the high prevalence of CVD in this population, and other non-traditional cardiovascular (CV) risk markers have now been described. Therefore, the potential relationship between CVD and phenotypic and genotypic risk markers was investigated prospectively in incident dialysis patients cohort. The 279 patients (244 on hemodialysis, 35 on peritoneal dialysis) within the Diamant Alpin Dialysis Cohort Study were investigated. Phenotypic and genotypic parameters were determined at dialysis initiation, patients monitored over a 2-year period, and CV events (morbidity and mortality) recorded. Globally, 82 CV events occurred and 26 patients (9.3%) died from CVD, whereas 28 (10%) died from non-CV causes. Previous CV events were strongly predictive of CV events occurrence, whatever patients had had one (hazard ratio (HR) 2, 95% confidence intervals (CI) 1.1-3.5) or more (HR 3.9, 95% CI 2.1-7.1) CV accidents before starting dialysis. Both lipoprotein(a) (HR 1.67, 95% CI 1-2.5) and total plasma homocysteine at cutoff 30 micromol/l (HR 1.7, 95% CI 1.1-2.8) were independent predictors of CV events outcome. In the subgroup of patients with homocysteine < 30 micromol/l, methylenetetrahydrofolate reductase (MTHFR) TT was the sole biological parameter predictive of CV event outcome (HR 2.5, 95% CI 1.1-10, P = 0.03). ESRD patients who enter chronic dialysis with a previous CV event, high total homocysteinemia levels, or MTHFR 677TT genotype must be considered at high risk of incident CV events.

Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

Among currently available vascular access options for hemodialysis, central venous catheters show the poorest reliability, with frequent complications of thrombosis and stenosis impairing patency. The most serious problem, however, is catheter-related bloodstream infection (CRBI), which is typically a cause for removal of the catheter and protracted systemic antibiotic therapy. In our experience, a totally implanted device (Dialock^®, Biolink Corp.) seems to confer a better global protection against catheter-related infections than standard tunneled catheters, accounting for 0.97 vs. 4.75 infection episodes/1,000 catheter-days, respectively (p < 0.001). Bloodstream infection rates, however, are not statistically different in the two groups (0.85 vs. 0.81 per 1,000 catheter-days; p = n.s.), indicating that the improvement is mainly related to local cutaneous infections. On the other hand, in the Sodemann experience, a new taurolidine-based lock solution (Neutrolin^®, Biolink Corp.) greatly reduced CRBI rates with both subcutaneous ports and tunneled catheters to 0.29 and 0.20 episodes/1,000 catheter-days, respectively. These promising results await further confirmation from ongoing clinical trials.