Ilaria Petrucci

BACKGROUND: The effect of cinacalcet on the structural pattern of hyperplastic parathyroid glands was evaluated, using high-resolution colour Doppler (CD) sonography, in haemodialysis patients with severe, inadequately controlled, secondary hyperparathyroidism (sHPT). METHODS: Nine patients (6 males, 3 females; mean age +/- SD, 55.5 +/- 12.6 years) received cinacalcet, with adaptation of existing concomitant therapies. Biochemical parameters and the morphology and vascular pattern of hyperplastic parathyroid glands were measured at baseline and every 6 months thereafter, for a follow-up period of 24-30 months. RESULTS: At baseline, 28 hyperplastic glands were identified. Cinacalcet led to a reduction in glandular volume during the course of the study: 68% in glands with a baseline volume <500 mm(3) and 54% in glands with a baseline volume >or=500 mm(3). The mean volume +/- SD of glands <500 mm(3) changed significantly from the baseline (233 +/- 115 mm(3)) to the end of follow-up (102 +/- 132 mm(3), P = 0.007). Levels of mean serum phosphorus, calcium and calcium-phosphorus product decreased, but not significantly, whereas there were significant decreases in mean parathyroid hormone +/- SD levels (1196 +/- 381 pg/ml versus 256 +/- 160 pg/ml; P < 0.0001) and alkaline phosphatase +/- SD levels (428 +/- 294 versus 223 +/- 88 IU/l; P = 0.04), accompanied by an improvement in a subjective clinical score. CONCLUSIONS: Cinacalcet, in combination with conventional treatments, led to an improvement in biochemical and clinical parameters of sHPT and reduced glandular volume in patients with severe sHPT. Volume reduction was more evident in smaller glands. Longer term, larger, randomized clinical trials are needed to confirm these preliminary findings and to further define a more systematic approach in the treatment of sHPT.

Abstract Chronic kidney disease (CKD) includes all clinical features and complications during the progression of various kidney conditions towards end-stage renal disease (ESRD). These conditions include immune and inflammatory disease such as: primary and hepatitis C virus (HCV)-related glomerulonephritis; infectious disease such as pyelonephritis with or without reflux and tuberculosis; vascular disease such as chronic ischemic nephropathy; hereditary and congenital disease such as polycystic disease and congenital cystic dysplasia; metabolic disease including diabetes and hyperuricemia; and systemic disease (collagen disease, vasculitis, myeloma). During the progression of CKD, ultrasound imaging and color Doppler imaging (US–CDI) can differentiate the etiology of the renal damage in only 50–70% of cases. Indeed, the end-stage kidney appears shrunken, reduced in volume (Ø &amp;lt; 9 cm), unstructured, amorphous, and with acquired cystic degeneration (small and multiple cysts involving the cortex and medulla) or nephrocalcinosis, but there are rare exceptions, such as polycystic kidney disease, diabetic nephropathy, and secondary inflammatory nephropathies. The main difficulties in the differential diagnosis are encountered in multifactorial CKD, which is commonly presented to the nephrologist at stage 4–5, when the kidney is shrunken, unstructured and amorphous. As in acute renal injury and despite the lack of sensitivity, US–CDI is essential for assessing the progression of renal damage and related complications, and for evaluating all conditions that increase the risk of CKD, such as lithiasis, recurrent urinary tract infections, vesicoureteral reflux, polycystic kidney disease and obstructive nephropathy. The timing and frequency of ultrasound scans in CKD patients should be evaluated case by case. In this review, we will consider the morpho-functional features of the kidney in all nephropathies that may lead to progressive CKD.

AIMS: Since December 2015, the European/International Fibromuscular Dysplasia (FMD) Registry enrolled 1022 patients from 22 countries. We present their characteristics according to disease subtype, age and gender, as well as predictors of widespread disease, aneurysms and dissections. METHODS AND RESULTS: All patients diagnosed with FMD (string-of-beads or focal stenosis in at least one vascular bed) based on computed tomography angiography, magnetic resonance angiography, and/or catheter-based angiography were eligible. Patients were predominantly women (82%) and Caucasians (88%). Age at diagnosis was 46 ± 16 years (12% ≥65 years old), 86% were hypertensive, 72% had multifocal, and 57% multivessel FMD. Compared to patients with multifocal FMD, patients with focal FMD were younger, more often men, had less often multivessel FMD but more revascularizations. Compared to women with FMD, men were younger, had more often focal FMD and arterial dissections. Compared to younger patients with FMD, patients ≥65 years old had more often multifocal FMD, lower estimated glomerular filtration rate and more atherosclerotic lesions. Independent predictors of multivessel FMD were age at FMD diagnosis, stroke, multifocal subtype, presence of aneurysm or dissection, and family history of FMD. Predictors of aneurysms were multivessel and multifocal FMD. Predictors of dissections were age at FMD diagnosis, male gender, stroke, and multivessel FMD. CONCLUSIONS: The European/International FMD Registry allowed large-scale characterization of distinct profiles of patients with FMD and, more importantly, identification of a unique set of independent predictors of widespread disease, aneurysms and dissections, paving the way for targeted screening, management, and follow-up of FMD.

Arteriovenous fistula (AVF) complications are classified based on fistula outcomes. This review aims to update colour Doppler (CD) and pulse wave Doppler (PWD) roles in managing early and late complications of the native and prosthetic AVF. Vascular access (VA) failure occurs because inflow or outflow stenosis activates Wirchow's triad inducing thrombosis. Therefore, the diagnosis of the tributary artery and outgoing vein stenosis will be the first topic considered. Post-implantation complications occur from the inability to achieve AVF maturation and dialysis suitability due to inflow/outflow stenosis. Late stenosis is usually a sequence of early defects repaired to maintain patency. Less frequently, in the mature AVF or graft, complications are acquired 'de novo'. They derive either from incorrect management of vascular access (haematoma, pseudoaneurysm, prosthesis infection) or wall pathologies (aneurysm, myxoid valve degeneration, kinking, coiling, abnormal dilation from defects of elastic structures). High-resolution transducers (10-20 MHz) allow the characterization of the wall damage, haemodynamic dysfunctions, early and late complications even if phlebography remains the gold standard for the diagnosis for its sensitivity and specificity.

Vascular access (VA) is the lifeline for the hemodialysis patient and the native arterio-venous fistula (AVF) is the first-choice access. Among the different tests used in the VA domain, color Doppler ultrasound (CD-US) plays a key role in the clinical work-up. At the present time, three are the main fields of CD-US application: (i) evaluation of forearm arteries and veins in surgical planning; (ii) testing of AVF maturation; (iii) VA complications. Specifically, during the AVF maturation, CD-US allows to measure the diameter and flow volume in the brachial artery and calculate the peak systolic velocity (PSV) of the arterial axis, anastomosis and efferent vein, to detect critical stenosis. The borderline stenosis, revealed by the discrepancies between access flow rate and PSV, should be followed up with subsequent tests to detect progression of stenosis; the cases with significant changes in brachial flow should be referred to angiography. In conclusion, clinical monitoring remains the backbone of any VA program. CD-US is of utmost importance in a patient-centered VA evaluation, because it allows the appropriate management of all aspects of VA care. These are the main reasons why we strongly advocate the adoption of a VA surveillance program based on CD-US.