The optimal vascular access for elderly patients remains a challenge due to the difficult balance between risks and benefits in a population with increased comorbidity and decreased survival. Long dependence to central vein catheter, patient comorbidities, life expectancy, and complication rates are important influencing the indications for arteriovenous fistula or an arteriovenous graft. Although central vein catheters are simpler way to start a hemodialysis treatment, elderly patients are also at higher risk of death from infection or other complications associated with them more than for younger patients. The discussion revolves around the following key questions: What are the limiting factors for a vascular access in the elderly patients? Central venous catheter—is it still an option for elderly patients? Is still the autologous arteriovenous fistula playing a pivotal role as hemodialysis access in the elderly patients? Are there any real surgical contraindication to perform a vascular access in elderly patients? Is the old age a limiting factor for the vascular access management?

Diabetic nephropathy is one of the most frequent microvascular complications in diabetic patients. This report describes a case of diabetic nephropathy in an male adult (diabetic) patient treated with standard therapy and the contribution of the new antidiabetic drugs on the progression of the disease. We will deal the following questions: 1. What do we know about diabetic nephropathy and its natural history? 2. How should we manage diabetic nephropathy and what do the guidelines suggest on hyperglycemia? 3. How do we manage hyperglycemia in diabetic patients with chronic kidney disease (CKD)? Standard treatment. 4. What's news about antidiabetic medication? New treatment. 5. What's next?

Background The predictive value of preimplantation biopsies for long-term graft function is often limited by conflicting results. The aim of this study was to evaluate the influence of time-zero graft biopsy histological scores on early and late graft function, graft survival and patient survival, at different time points. Methods We retrospectively analyzed 284 preimplantation biopsies at a single center, in a cohort of recipients with grafts from live and deceased donors (standard and nonstandard), and their impact in posttransplant renal function after a mean follow-up of 7 years (range 1–16). Implantation biopsy score (IBS), a combination score derived from 4 histopathological aspects, was determined from each sample. The correlation with incidence of delayed graft function (DGF), creatinine clearance (1st, 3rd and 5th posttransplant year) and graft and patient survival at 1 and 5 years were evaluated. Results Preimplantation biopsies provided somewhat of a prognostic index of early function and outcome of the transplanted kidney in the short and long term. In the immediate posttransplantation period, the degree of arteriolosclerosis and interstitial fibrosis correlated better with the presence of DGF. IBS values between 4 and 6 were predictive of worst renal function at 1st and 3rd years posttransplant and 5-year graft survival. The most important histological finding, in effectively transplanted grafts, was the grade of interstitial fibrosis. Patient survival was not influenced by IBS. Conclusions Higher preimplantation biopsy scores predicted an increased risk of early graft losses, especially primary nonfunction. Graft survival (at 1st and 5th years after transplant) but not patient survival was predicted by IBS.

Aims and background Left ventricular hypertrophy (LVH) is a common finding in hemodialysis patients. The aim of the present study was to investigate if the diameter of the distal radiocephalic fistula could influence left ventricular variables in stable hemodialysis patients. Methods Nineteen patients were investigated. Measurements of the diameter of the arteriovenous (AV) fistula were performed in 4 different locations. The patients were investigated using M-mode recordings and measurements in the 2D image. Doppler ultrasound was also performed. Transonic measurements were performed after ultrasound investigation. Results Fistula mean and maximal diameter correlated with left ventricular characteristics. Fistula flow correlated neither with the left ventricular characteristics nor with fistula diameters. Conclusions The maximal diameter of the distal AV fistula seems to be a sensitive marker of LVH in stable hemodialysis patients.

A case of hyponatremia in a previously healthy 76-year-old woman is described with discussion revolving around key questions: 1. Is hyponatremia really hypotonic? 2. Is there an emergency present on admission necessitating acute therapeutic action to improve the electrolyte disturbances? 3. What is the best approach to obtaining a correct diagnosis? 4. What is the best approach to raise serum Na? 5. What are the risk factors, symptoms and pathophysiology of thiazide-induced hyponatremia? 6. What is the role of hypokalemia in the pathophysiology of hyponatremia? 7. What are the options for therapy to raise the plasma sodium in this patient? 8. How should the concomitant hypokalemia be treated, and is it an additional danger in the treatment of the hyponatremia? 9. What are the lessons from this case for the management of chronic “asymptomatic” or mildly symptomatic hyponatremic patients? 10. Would this patient be approached differently in Europe and the United States?