Acute kidney injury (AKI), either of pre-renal, renal, or post-renal origin, is an important complication in cancer patients resulting in worse prognosis, withdrawal from effective oncological treatments, longer hospitalizations, and increased costs. The aim of this paper is to give a literature review of general and cause-specific treatment strategies of AKI, providing a helpful guide for clinical practice. We propose to classify AKI as patient-related, cancer-related, and treatment-related, in order to optimize therapeutic interventions. In the setting of patient-related causes, proper assessment of hydration status, and avoidance of concomitant nephrotoxic medications is key. Cancer-related causes mainly encompass urinary compression/obstruction, direct tumoral kidney involvement and cancer-induced hypercalcemia. Rapid recognition and specific treatment can potentially restore renal function. Finally, a pretreatment comprehensive evaluation of risks and benefits of each treatment should always be performed to identify patients at high risk of treatment-related renal damage, and allow the implementation of preventive measures, without losing the potentialities of the oncological treatment. Considering the complexity of this field, a multidisciplinary approach is necessary with the goal to reduce the incidence of AKI in cancer patients and improve patient outcome. The overriding research goal in this area is to gather higher quality data from international collaborative studies.

Bone Biopsy (BB) with histomorphometric analysis still represents the gold standard for the diagnosis and classification of different forms of renal osteodystrophy. Bone biopsy is the only technique able to provide comprehensive information on all bone parameters, measuring static and dynamic parameters of turnover, cortical and trabecular microarchitecture, and mineralization defects. In nephrological practice, bone biopsy yields relevant indications to support therapeutic choices in CKD, heavily impacting the management and prognosis of uremic patients. Unfortunately, the use of bone biopsy has decreased; a lack of expertise in performing and interpreting, perceived procedure invasiveness and pain, and reimbursement issues have all contributed to this decline. Nevertheless, both bone biomarkers and instrumental images cannot be considered reliable surrogates for histological findings, being insufficiently accurate to properly evaluate underlying mineral and bone disorders. This is a multidisciplinary position paper from the Nephrology and Osteoporosis Italian Scientific Societies with the purpose of restating the role of bone biopsy in CKD patient management and of providing strong solutions to allow diffusion of this technique in Italy, but potentially also in other countries. The Italian approach through the optimization and standardization of bone biopsy procedure, the construction of the Italian Hub and Spoke network, and a request for adjustment and national homogenization of reimbursement to the Italian Health Ministry has led the way to implement bone biopsy and to improve CKD patient management and prognosis.

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