Proteinuria is a broad term used to describe the pathological presence of proteins, including albumin, globulin, Bence-Jones protein, and mucoprotein in the urine. When persistent, proteinuria is a marker of kidney damage and represents a reliable predictor of the risk of progression of renal failure. Medical nutrition therapy is imperative for patients with proteinuria because it may slow the progression of renal disease. The aim of this review is to explore different nutritional approaches in the management of proteinuria and their influence on pathophysiological processes. As such, protein restriction is the main dietary intervention. Indeed, other management approaches are frequently used to reduce it regarding micro and macronutrients, but also the dietary style. Among these, the nutritional approach represents one of the most used and controversial interventions and the studies rarely take the form of randomized and controlled trials. With this work we aspire to analyze current clinical knowledge of how nutrition could influence proteinuria, potentially representing a useful tool in the management of proteinuric nephropathy.

Autogenous (AVF) and prosthetic (AVG) arteriovenous fistulas are the vascular accesses (VA) of choice for hemodialysis thanks to their improved patency, reduced costs, and lower rate of infections relative to catheters. In an effort to maximize the number of primary AVF and AVG, shorten maturation times for AVF, and reduce the number of indwelling catheters, several new techniques have been developed within the context of an overall program designed to optimize access care. This approach includes: (a) Primary Intraoperative Balloon Angioplasty on the vessels selected for AV creation whether small-sized or altered by pre-existing lesions; (b) Percutaneous Transluminal Angioplasty (PTA) on AVF and AVG stenosis, performed under ultrasonographic (UG) or fluoroscopic guide (FG). We report the experience of two Center in performing the above mentioned procedures on even complex VA. The wise adoption of these techniques may avail to meet the stringent demands for reliable VA placement as defined by KDOQI and, thereby, expand the duration and quality of life for hemodialysis patients.

Guidelines for vascular access recommend that the distal autogenous arteriovenous fistula (AVF) should be the first choice-access procedure for patients starting dialysis. Arteriosclerosis of radial artery may cause early failure, as well as failure of maturation of distal arteriovenous fistulas. To increase the incidence of distal AVFs, our team, specialized in vascular access surgery from 2004 onwards, has introduced Intraoperative Transluminal Angioplasty (ITA) under ultrasound (UG) or fluoroscopic guidance, to recruit inadequate arterials for creating distal fistulas. Intravascular lithotripsy (IL) is a novel approach to treat luminal and medial calcifications in patients with peripheral arterial disease and coronary disease. We believe that intraoperative IL may be an opportunity to recruit calcified radial arteries for creating distal radio-cephalic fistulas. Purpose of this study is to describe the intraoperative IL technical applied in our clinical experience. A 37-year-old diabetic patient with distal radio-cephalic fistula was recruited for the first IL experience. One year ago, a wrist radio-cephalic fistula was created in the right upper limb, with intraoperative UG radial artery angioplasty for extensive calcifications. The fistula was functioning but showed a delay in maturation. An angioplasty was unsuccessfully attempted to facilitate the maturation. Subsequently, a surgical revision of the fistula was performed, creating a new anastomosis immediately upstream of the previous one by performing an intraoperative IL UG of the radial artery. The fistula was immediately well functioning, and was cannulated with two needles after 1 month. It is currently being used with intradialytic adequate blood flow. The positive outcome of the case described in this paper, even if only anecdotal, could act as a trigger for further experiences with IL.

Background: Hepatitis C virus (HCV) may play a pathogenic role in several forms of immune complex glomerulonephritis (GN). We present a patient whose initial clinical presentation instilled suspicion of HCV-related renal involvement. Yet, histopathologic data oriented towards a different diagnosis. Case presentation: A 68-year old man presented with kidney dysfunction, cryoglobulins, low C4 level, high HCV—RNA and cutaneous vasculitis. The first hypothesis was a hepatitis C-related cryoglobulinemic glomerulonephritis. Renal biopsy revealed endocapillary and mesangial cells hypercellularity with complement C3 and IgM deposits. The echocardiography showed an infectious endocarditis (IE) on aortic valve. Appropriate antibiotic therapy and a prosthetic valve replacement were performed, obtaining recovery of renal function. Conclusion: HCV infection may be linked to multiple renal manifestations, often immune-complex GN such as cryoglobulinemic membrano-proliferative GN. Renal disease due to IE is usually associated to focal, segmental or diffuse proliferative GN, with prominent endocapillary proliferation. The most common infectious agents are Staphylococcus aureus and Streptococcus species. This case report may be relevant because the renal dysfunction was highly suggestive of a cryoglobulinemic GN on a clinical ground, but the histologic pattern after performing the renal biopsy oriented towards a different cause of the underlying disease, that required a specific antibiotic treatment. The renal biopsy is always required to confirm a clinical suspicious in patients affected by multiple comorbidities.

Maturation failure remains a major clinical problem of distal arteriovenous fistula (AVF). Early failure (EF) is associated with the small size of the veins. For about 10 years we have used in more than 1000 fistulas, the Vessels Pre-Dilatation (VPD) to increase the recruitment of small veins for creating distal AVFs. The purpose of this study is to highlight if the VPD can reduce the incidence of EF or failure to mature (FTM) in AVFs created with small veins. Data of all the consecutive patients directly admitted to our Department for their first distal AVF from January to December 2019 were collected. The patients were divided in two groups, one with a vein diameter after the tourniquet ⩽2.0 mm (G1) and one >2 mm (G2). Both in G1 then in G2 the vessels had undergone VPD. Immediate failure (IF), EF, FTM, delayed or arrested maturation rate (DAM), unassisted AVFs and matured AFVs were evaluated. The patients recruited totalled 104, 37 in G1, and 67 in G2. The two groups were homogeneous in age, incidence of diabetes, obesity, heart disease, peripheral vasculopathy, and race. Female were more numerous in G1 (51% vs 12%, p < 0.001). In G1 and G2 occurred respectively 3 IF versus zero (p < 0.05), 10 EF (29%) versus 6 (9%) (p < 0.05), 6 DAM (16%) versus 6 (9%), 21 unassisted AVFs (57%) versus 57 (85%) (p < 0.01). Dividing the patients into groups of unassisted and assisted AVFs, female and low vein diameter are more represented in the assisted group. There were 32 matured AVFs (86%) in G1 and 65 (97%) in G2. In order to increase the incidence of the distal AVF, the PDV allows to include small veins. However, more patients require further interventions to achieve maturation of the fistula.

BACKGROUND Pleuroperitoneal communication (PPC) is a rare yet significant complication in patients undergoing peritoneal dialysis (PD), characterized by an abnormal connection between the peritoneal and pleural cavities. This condition can lead to pleural effusion, respiratory complications, and, in severe cases, necessitate the discontinuation of PD in favor of hemodialysis, threatening residual renal function. While the incidence of PPC is low (1-6%), it presents considerable diagnostic and therapeutic challenges, often requiring a multidisciplinary approach. CASE REPORT We report 2 cases of PPC managed at our center, highlighting the role of advanced diagnostic and therapeutic strategies. Both cases were diagnosed via peritoneal scintigraphy using 99mTc-labeled albumin and confirmed with computed tomography (CT). The first case, a female patient, transitioned to extracorporeal dialysis following diagnosis. The second case, a male patient, initially underwent conservative management with a very-low-protein diet for 45 days. Follow-up scintigraphy showed resolution of the leakage. However, approximately 1 month after resuming peritoneal dialysis, he had a recurrence. After implementation of an optimized nutritional protocol and a consultation with a thoracic surgeon, a decision was made to proceed with minimally invasive repair via video-assisted thoracic surgery (VATS). This approach included defect closure with Prolene® sutures and fibrin glue application. VATS allowed resolution of the complication and postoperative PD resumption with reduced volumes. CONCLUSIONS Our findings emphasize the importance of early diagnosis using advanced imaging, tailored nutritional therapy to bridge treatment, and minimally invasive surgical techniques to preserve PD and renal function. Peritoneal scintigraphy offers high precision in mapping the anatomical defect, facilitating targeted surgical intervention VATS. Combined with preoperative imaging, it proved to be a precise and effective intervention. Dietary intervention successfully prevented the transition to extracorporeal dialysis. A multidisciplinary team involving nephrologists, thoracic surgeons, nuclear medicine specialists, and dietitians was crucial for optimizing outcomes. Future research should focus on standardizing diagnostic protocols and surgical techniques to improve PPC management, reduce recurrence, and enhance patient quality of life.