Intra-dialytic blood oxygen saturation (SO2): association with dialysis hypotension (the SOGLIA Study).

BACKGROUND: Intradialytic hypotension (IDH) has a dramatic impact on the main outcomes of dialysis patients. Early warning of hemodynamic worsening during dialysis would enable preventive measures to be taken. Blood oxygen saturation (SO2) is used for hemodynamic monitoring in the critical care setting and may provide useful information about IDH onset. AIM: To evaluate whether short- and medium-term variations in the SO2 signal (ST-SO2var, MT-SO2var,) during dialysis are a predictor of IDH. METHODS: In this 3-month observational cohort study, 51 hypotension-prone chronic hemodialysis (HD) patients, with vascular access by arteriovenous fistula (AVF) or central venous catheter (CVC), were enrolled. Continuous non-invasive blood SO2 was monitored (fc = 0.2 Hz) by an optical sensor on the arterial line of the extracorporeal circulation; blood pressure (every 30 min), symptoms and their time of appearance were noted. Predictive power of IDH was expressed by the area under curve (AUC) sensitivity and specificity based on intradialytic variations in SO2. RESULTS: A total of 1290 HD sessions were analyzed. Overall, off-line ST-SO2var analysis proved able to correctly predict IDH in 67 % of the sessions where IDH occurred. The best predictive performance was found in the presence of highly arterialized AVF (SO2 > 95 %) (75 % sensitivity; AUC 0.825; p < 0.05). On the contrary, in sessions with CVC, IDH prediction proved more efficient by MT-SO2var (AUC 0.575; p = 0.01). CONCLUSIONS: Intradialytic SO2 variability could be a valid parameter to detect in advance the hemodynamic worsening that precedes IDH. Appropriate timely intervention could help prevent IDH onset.

Morbid obesity in a young woman affected by advanced chronic kidney disease: an exceptional case report. Does a high dose of essential amino acids play a key role in therapeutic success?

A 38-year-old woman, obese (219 kg), diabetic, hypertensive, chronic kidney disease (CKD) stage 4, with low plasma albumin level (2.9 g dl(-1)) and marked proteinuria (22 g per day) was studied. Given the advanced-stage CKD with nephrotic proteinuria, we supplemented low-protein diet with high doses of a tailored essential amino acid mixture (AAs: 44 g per day) to improve weight reduction in the patient. After 20 months of conservative therapy, the patient lost 43 kg; despite two episodes of infection, albumin plasma levels increased up to 3.7 g per day. After a further 20 months of dialysis, the patient maintained a diet of 1800 kcal supplemented with 32 g of AAs and lost 47 kg, whereas both albumin (3.89±0.12 g dl(-1)) and C reactive protein returned to normal. During the follow-up period, anemia improved, erythropoietin was thus discontinued and insulin requirement decreased to 105 IU. This therapeutic option may be beneficial in advanced CKD patients with obesity and diabetes resulting from malnutrition.

Erythropoiesis-stimulating agents: switch from intravenous to subcutaneous administration in hemodialyzed patients.

UNLABELLED: The aim of this study was to undertake a long-term comparison of hemodialyzed patients who had undergone IV administration of ESAs and subsequently switched to SC administration, focusing particularly on the numerous comorbidity factors and the possible savings implicated in the switch. A total of 75 patients were treated as follows: 12% epo-alpha 33.3% epo-beta 54.6% darbepoetin IV for a period of 12 months followed by a second 12-month SC. The following parameters were evaluated: Charlson Comorbidity Index (CCI), Geriatrics index of comorbidity, iron storage pool, CRP, iPTH, dry weight, eKt/V, total protidemia and albumin, dose and type of: ESAs used, iv iron, vitamin C, vitamin B12, folates, vitamin D and derivatives, calcimimetic and ACEi, /month, and finally the cost of iv vs. sc treatment. No clinical or blood chemistry variations were observed during the study, with the exception of a significant increase of Hb from 11.2 ± 1.1 to 11.6 ± 0.9 g/dl (p = 0 .001). The total yearly cost for all 75 patients treated with ESAs amounted to 191,278 € for IV administration compared to 154,016 € for SC administration, with an overall saving of 19.4%. CONCLUSION: The subcutaneous route of administration is considered the safest, and the significant cost savings incurred at minimum discomfort for patients should not be overlooked. No costs saving were obtained for darbepoetin with regard to subcutaneous administration. Furthermore, Epo-beta sc is frequently characterised by the potential effect of extending intervals between administrations maintaining constant levels of Hb.

Hemodiafiltration with endogenous reinfusion with and without acetate-free dialysis solutions: effect on ESA requirement.

BACKGROUND: Hemofiltrate reinfusion (HFR) is a form of hemodiafiltration (HDF) in which replacement fluid is constituted by ultrafiltrate from the patient 'regenerated' through a cartridge containing hydrophobic styrene resin. Bicarbonate-based dialysis solutions (DS) used in routine hemodialysis and HDF contain small quantities of acetate (3-5 mM) as a stabilizing agent, one of the major causes of intradialytic hypotension. Acetate-free (AF) DS have recently been made available, substituting acetate with hydrochloric acid. The impact of AF DS during HFR on Hb levels and erythropoietic-stimulating agent (ESA) requirement in chronic dialysis patients was assessed. PATIENTS AND METHODS: After obtaining informed consent, 30 uremic patients treated by standard bicarbonate dialysis (BHD, DS with acetate) were randomized to treatment in 3-month cycles: first AF HFR, followed by HFR with acetate, and again AF HFR. At the beginning and end of each period, Hb and ESA requirements were evaluated. RESULTS: A significant increase in the Hb level was observed throughout all periods of HFR versus BHD (from 11.1 to 11.86 g/dl; p = 0.04), with a significant decrease of ESA requirements from 29,500 to 25,033 IU/month (p = 0.04). CONCLUSION: Regardless of the presence or absence of acetate in DS, HFR per se allows a significant lowering of ESA dosage versus BHD, while at the same time increasing Hb levels. Taking for granted the clinical impact produced, HFR seems to provide a relevant decrease in end-stage renal disease patient costs.

[Pro convection: are convective therapies like hemodiafiltration and hemofiltration the future of extracorporeal blood purification?]. / Pro convezione: le terapie convettive: emodiafiltrazione ed emofiltrazione, futuro della depurazione extracorporea?

In recent years, the age and clinical gravity of hemodialysis patients have been steadily increasing. This unavoidable phenomenon is progressively leading Italian and European nephrologists to perform negative patient selection by treating symptomatic and/or critical cases with extracorporeal blood purification methods that decrease symptoms during sessions and result in reduced morbidity and mortality. While recent studies have failed to confirm the effectiveness of convective therapies in terms of mortality, more recently the advent of online convective therapies has enabled high fluid volume exchange, leading to improved clinical status and purification outcome. These therapies could offer a valid, perhaps even better alternative to mainly diffusive extracorporeal treatments, whether intermittent, daily or 'long and slow'. Indeed, convective therapies, especially biofiltration and/or acetate-free procedures, are able to efficiently purify the blood from molecules that have a major impact on patients' clinical-nutritional and inflammatory status, such as AGEs, myoglobin, osteocalcin, TNF-alpha, homocysteine, ADMA, complement factor D, and phosphates. Moreover, many studies have reduced the adverse effects of convection in terms of mortality: some aspects of the HEMO trial, the DOPPS study and many other European studies have been reassessed. Convective therapies in Europe and Italy differ from the high-flux methods used in the USA, where the convective component is markedly lower than that used in the European trials thanks to the possibility of performing high-infusate online exchanges at no cost. The indicators used for assessing the dialytic suitability of convective procedures should also be reassessed: urea Kt/V should be considerably downsized, and different markers could be used for more complete assessment, especially for medium- and large-molecular-weight uremic toxins, without neglecting the clinical and nutritional status of dialyzed patients. In the nephrologist's daily routine more time should be devoted to clinical assessment so that therapy can be personalized according to the needs of each patient.

Effect of on-line hemodiafiltration with endogenous reinfusion (HFR) on the calcium-phosphorus metabolism: medium-term effects.

AIM: The purpose of the study was to examine the effect of hemodiafiltration with endogenous reinfusion (HFR) compared to hemodialysis (HD) on 28 uremic patients with secondary hyperparathyroidism (2HPT) but positively selected for good and stable control of phosphatemia in order to evaluate the independent effects of dialysis treatments on bone turnover metabolism. METHODS: The study was divided into 3 periods of observation: a) HD for three months; b) HFR for three months; c) HFR for a further 3 months. We analysed the trend of: whole PTH, 1-84 PTH, 7-84 PTH, alkaline phosphatase and its bone isoenzyme, total and ionised calcium, phosphatemia, dose of phosphate binder agents, beta2-microglobulin, CRP. All the variations found were evaluated through mean values +/- SD, t-tests, multivariate analysis. RESULTS: We observed a deceleration in bone turnover characterized by a reduction of the total and bone alkaline phosphatase (IU/mL) from 92.3 +/- 82.8 and 35.8 +/- 49.8 at the end of HD to 63.4 +/- 23.9 and 16.0 +/- 8.7 at the end of HFR, respectively, and 1-84 PTH from 317.5 +/- 264.6 pg/mL at the end of HD to 287.5 +/- 258.9 pg/mL at the end of the 3rd month of HFR. Beta2-microglobulin was reduced from 32.9 +/- 16.1 mg/L at the end of HD to 26.4 +/- 8.1 mg/L already at the end of the first three months of HFR. CRP was reduced from 2.5 +/- 2.6 mg/dL at the beginning of the study to 1.3 +/- 1.7 mg/dL at the end of HFR. There were no differences with regard to: dialytic efficiency, nutritional status, calcemia, phosphatemia (maintained in the K-DOQI range for the entire duration of the study), also thanks to more careful use of phosphate chelating agents. CONCLUSION: We are of the opinion that HFR - essentially thanks to the use of ultrapure endogenous infusate - induces a deceleration in bone turnover due to 2PHT. In addition, phosphate subtraction in HFR is better compared to HD, thanks to the improvement of the anti-inflammatory conditions by removing the cytokines harmful to bone metabolism and excluding a priori the negative effects related to hyperphosphatemia.

Role of SPECT/CT in the preoperative assessment of hyperparathyroid patients.

PURPOSE: Our purpose was to assess the clinical value and additional benefit of fusion single-photon computed tomography (SPECT) and computed tomography (CT) images in locating the parathyroids in a selected group of patients affected by primary (PHP) and secondary hyperparathyroidism (SHP). MATERIALS AND METHODS: Sixteen patients (11 women and five men; age range 35-80 years) with severe hyperparathyroidism (HP) (ten PHP, six SHP) were studied by ultrasound (US), and, after i.v. injection of 370 MBq of 99mTc-sestamibi, by planar parathyroid scintigraphy, SPECT and SPECT/CT using a dual-detector scintillation camera GE Infinia Hawkeye. All patients underwent parathyroidectomy. RESULTS: US findings were inconclusive in 12/16 patients affected by multinodular goitre, and two probable eutopic parathyroid glands were identified. "Double phase" parathyroid scintigraphy identified 14 probable parathyroid glands, SPECT 23 (14 ectopic and nine eutopic) and SPECT/CT confirmed all 23 probable parathyroid lesions, offering more precise localisation and an evident improvement in diagnostic accuracy. Sixteen of these foci of increased uptake were hyperplastic parathyroid glands, six were adenomas, one was a parathyroid carcinoma and one was a thyroid follicular carcinoma. Surgical detection of the 23 sestamibi-positive lesions was correctly matched with 100% of SPECT/CT images and 61% of SPECT data alone. Hybrid imaging thus provided additional data in 39% of lesions, and in three patients with retrotracheal glands, it modified the surgical approach. CONCLUSIONS: We believe 99mTc-sestamibi SPECT/CT to be a more reliable presurgical method to study a patient subgroup affected by PHP or SHP in whom conventional US and other scintigraphic methods have failed for intrinsic reasons due to the concomitant presence of multinodular goitre or ectopic parathyroid gland. The additional practical benefit derived from this methodology was evident. In fact, anatomical information provided by CT enables precise localisation of the functional abnormalities highlighted by SPECT, and both are essential to a correct surgical approach.

New method for phosphate kinetics estimation during hemodialysis and on-line hemodiafiltration with endogenous reinfusion.

AIM: The purpose of this study was to optimize the operative and analytical methodologies to a more exact determination of intradialytic kinetics of the phosphates (P) tested in hemodialysis (HD) and in on-line hemodiafiltration with endogenous reinfusion (HFR - Hemo Filtrate Reinfusion). METHODS: The mass balance measurements of urea and P were carried out in 18 clinically stable HD patients. The effective blood flow (Qb) was measured with a Transonic monitor. The plasma was deproteinized with 10% trichloroacetic acid to prevent breakdown of the proteins and the consequent pseudohyperphosphatemia. Subsequently the supernatant containing the ultrafiltrable phosphates was made to react with a solution of ammonium molybdate for a spectrophotometric reading. RESULTS: The mean urea mass transfer in HD was 16.9 g/session and in HFR 15.4 g/session. The mean P mass transfer in HD was 726 mg/session and in HFR 679 mg/session. Nevertheless, in HFR a significant difference was verified between the clearances of P, between the plasma water side (122.4 +/- 30.8 ml/min) and the dialysate side (105.9 +/- 19.4 ml/min). CONCLUSION: As far as the P mass transfer is concerned, the data obtained is able to be superimposed with that described in the literature during HD, while in HFR it is possible to hypothesize a high efficiency, thanks to an increased output of P in relation to the phenomenon of adsorption which, although is limited, contributes to the transfer of the total mass. Based on this study and re-examining the literature on P kinetics, there is space for methodological improvement both on the operating front with careful determination of the effective Qb, and on the chemical front overcoming the inaccuracy of automatic analyzers in determining the plasma P owing to possible overestimation of phosphatemia and poor sensitivity in measuring the lower levels of P present in the dialysate and/or ultrafiltrate.

[Guidelines on water and solutions for dialysis. Italian Society of Nephrology]. / Linee Guida su acque e soluzioni per dialisi.

The National Society of Nephrology has promoted the development of specific Italian Guidelines for dialysis fluids. Two previous national inquiries showed a wide variety in the type and frequency of both microbiological and chemical controls concerning dialysis water, reinforcing the need for specific standards and recommendations. An optimal water treatment system should include tap water pre-treatment and a double reverse osmosis process. Every component of the system, including the delivery of the treated water to the dialysis machines, should prevent microbiological contamination of the fluid. Regular chemical and microbiological tests and regular disinfection of the system are necessary. 1. Chemical quality (Table: see text). Treated tap water used to prepare dialysis fluid should be within European Pharmacopoeia limits at the water treatment system inlet and at the reverse osmosis outlet. In addition dialysate, concentrate and infusion fluids must comply with specific Pharmacopoeia limits. The physician in charge of the dialysis unit is advised to institute a multidisciplinary team to evaluate the requirement for added chemical controls in the presence of local hazards. 2. Microbiological quality (Table: see text). High microbiological purity of dialysis fluid--regularly verified--is a fundamental prerequisite for dialysis quality and every dialysis unit should aim as a matter of course to obtain "ultra-pure" dialysate (microbial count <0.1 UFC/mL, endotoxins <0.03 U/mL). On-line dialysate ultrafiltration and regular disinfection of dialysis machines greatly enhance microbiological purity. On-line dialysate reinfusion requires specific devices used according to corresponding instructions and to more frequent microbiological tests. Dialysis fluids for home dialysis should comply with the same chemical and bacteriological quality. The appendix reports the water treatment system's technical characteristics, sampling and analytical methods, monitoring time-tables, as well as the origin and effects of the main toxic substances. Suggestions and questions concerning these guidelines are welcome to nefrologia@sin-italy.org.

[The treatment of osteodystrophy in dialyzed uremic patients: results of the first Sardinian audit]. / Il trattamento dell'osteodistrofia nei pazienti uremici in dialisi: risultati del primo Audit sardo.

BACKGROUND: Hyperphosphatemia in the uremic patient undergoing dialysis causes and makes the secondary hyperpharatyroidism progress. Nowadays it has a very important role in predicting mortality. The aim of the study was to assess by "Audit" to analyse adequacy of the Sardinian dialytic patients with reference to the optimal objective of the national and international guidelines. PATIENTS AND METHODS: The questionnaire of the audit was composed of 11 questions about the percentage distribution of: calcium in the dialysate, values of phosphoremia), Ca x P product, patients treated with vitamin D taking one or more phosphate binders, average dose, spKt/V > or = 1.2, serum aluminium, parathiroidectomy. RESULTS: We examined 1274 dialysis patients (93% on hemodialysis and 7% in CAPD) in 26 dialytic centers in our region (age 63.8 anni +/- 32.4; dialytic age 5.15 +/- 5.06. Phosphorus ranges (mg/dL) P < 5.5: 61.3 +/- 23%; between 5.5 e 6.5: 28.2 +/- 17.7%; and P > 6.5: 10.4 +/- 7.7%; Ca x P (<60): 77.8% +/- 16.6%; between 60-70: 16.8 +/- 13.4%; > 70: 4.99 +/- 4.7%. The more prescribed dialysate calcium was 1.5 mmol/L in HD (58.8%) HF (60.6%), HDF (51.6%) and CAPD (5.6%). PTH levels were: 31.1% (<120); 29.5% (120-250); 21.1% (250-450); 8% (450-600); 10.3% (>600). Patients on vitamin D: os daily 23.04 +/- 28%; post-dialysis boluses: os 32.6 +/- 28, i.v. 10.6 +/- 9%; no therapy 32.7 +/- 22.7%. The percentage use of phosphorus binders: 48.5% calcium carbonate (2.9 g/d); 7.12% calcium acetate (1.34 g/d); 13.5% sevelamer (2.79 g/d); 10% total aluminium based (0.62 g/d). The aluminium is dosed in 11/26 dialysis units (32.3% of the population); 2.3% +/- 0.9% of patients having Aluminium > 30 mcg/L. The dialytic patients have a Kt/V > or = 1.2: 80.1 +/- 19%. Parathyroidectomy incidences 1.8%. CONCLUSIONS: The data show good control of the average phosporous, there is a worrying percentage of patients with PTH values compatible with hypodynamic bone condition, lower and therefore safer calcium levels in the dialysate, poor aluminium control and low incidence of parathyroidectomy. In our experience the audit is a good way to verify and to correct the therapeutic choice in uremic osteodistrophy.

Role of proteinuria reduction in the progression of IgA nephropathy.

UNLABELLED: Proteinuria has been shown to play a causal role in the progression towards ESRD of IgA nephropathy (IgAN). We demonstrated that steroids are effective in reducing proteinuria and preserving renal function. AIM: to evaluate the long-term effect of steroids in IgAN patients (6th year evaluation) and better clarify the role of proteinuria reduction in slowing down the progression. METHODS: multicenter randomized controlled trial of 86 adult IgAN patients with serum creatinine < or = 1.5 mg/ dL and moderate proteinuria. They received either supportive therapy or methylprednisolone 1-g i.v. for three days at months 1, 3, and 5, plus oral prednisone (0.5 mg/kg every other day for six months). RESULTS: Proteinuria significantly decreased in the treated patients (from 2.0+/-0.60 g/24 h at baseline to 1.0+/-0.68 g/24 h at six months) and remained stable till the 6th year (0.67+/-0.5 g/24 h), it slightly decreased in the control group. Six-year renal survival was significantly better in the steroid than in the control group: 9 patient (20.9%) in the steroid group and 15 (34.8%) in the control group reached the primary end-point of a 50% increase in serum creatinine from baseline. Five controls and none of the steroid-treated patients started dialysis. Steroid-treated patients did not experience any major side effects during follow-up. CONCLUSIONS: Steroids significantly reduce proteinuria and protect against renal function deterioration in IgAN patients. Early reduction of proteinuria could also be marker of a persistent reduction in its levels over time and of a better outcome in the long term.

Predilution haemofiltration--the Second Sardinian Multicentre Study: comparisons between haemofiltration and haemodialysis during identical Kt/V and session times in a long-term cross-over study.

BACKGROUND: The potential superiority of various renal replacement treatment modalities consisting largely of convective mass transfer as opposed to primarily diffusive mass transfer, is still a matter of debate. The objective of the present study was to evaluate acute and long-term clinical effects of varying degrees of convection and diffusion in a group of 24 clinically stable patients with end-stage renal disease. METHODS: The patients were prospectively assigned to three consecutive treatment schedules of 6 months each: phase I (HF1) (on-line predilution haemofiltration)-->phase II (HD) (high-flux haemodialysis)-->phase III (HF2; as phase I). We used the AK100/200 ULTRA monitor (Gambro), which prepares ultrapure dialysis fluid for HD and sterile, pyrogen-free substitution solution for HF. The membrane (polyamide), fluid composition, and treatment time were the same on HF and HD. The targeted equilibrated Kt/V was 1.2 for both treatment modes, creating a similar urea clearance. RESULTS: Fifteen patients, mean age 62.8+/-8.4 years, completed the study according to the above conditions. Urea kinetics, nutritional parameters, and dry weight were similar in the three periods. The frequency of intra-treatment episodes of hypotension/patient/month was significantly lower on HF1 (1.24) and HF2 (1.27) than on HD (1.80) (P<0.04). It decreased progressively on HF1, then increased on HD, and decreased again during HF2. Patients had fewer muscular cramps on HF than on HD (P<0.03) and required significantly less saline and plasma expander during HF than HD sessions. The prevalence of inter-treatment symptoms, including fatigue and hypotension, was lower on HF than on HD (score difference P=0.04). Quality of life, determined by the Laupacis method in all three periods, showed a tendency towards improvement during the study, reaching the best values during HF2. CONCLUSIONS: HF has a progressive stabilizing haemodynamic effect, producing a more physiological cardiovascular profile than HD. This long-term effect, observed in stable patients treated under strictly identical conditions, is probably due to the mechanism of convection, and is different from the acute effect observed mainly in unstable patients.

Adequacy in pre-dilution haemofiltration: Kt/V or infusion volume? The Sardinian Collaborative Study Group on Haemofiltration On-line.

Kt/V is the main index of adequacy for diffusive and diffusive convective methods of extracorporeal depuration, yet there exists no universally acceptable validation of an adequacy index for the solely convective methods such as haemofiltration (HF). The aim of the present study is to analyse which of the parameters of adequacy used in two multicentre HF studies, Kt/V for urea or infusion volume, correlate best with nutritional parameters and can therefore be utilized for the evaluation of treatment dose in on-line pre-dilution HF. Twenty-three clinically stable patients were enrolled in the first study [3 months of haemodialysis (HD)+ 3 months of HF]. In the second study, 24 stable patients were studied in three phases: 6 months in HF, 6 months in HD and a further 6 months in HF; in this study, a target of Kt/V= 1.2 in all three periods was preestablished: 15 patients completed the full study. In both studies, we utilized the same monitor (AK 100/200 Ultra, Gambro), the same membrane (polyamide) and the same on-line prepared ultrapure dialysis fluid and sterile infusion solution. In both studies, we ensured that HF fulfilled the following parameters of adequacy: urea kinetics, cardiovascular and blood pressure stability (better in HF than in HD), common haematochemical and nutritional parameters, reduction in beta2-microglobulin levels, a good intra- and extra-session clinical outcome, and a good quality of life with morbidity and mortality rates no different from those of HD. HF proved to be an efficacious method of ensuring adequate depuration and a good quality of life for uraemic patients. We have shown that in longer periods of HF, a notable correlation between Kt/V and normalized protein catabolic rate (nPCR) and an equally good correlation between total ultrafiltration (UF)/dry weight ratio and nPCR could be achieved. In both studies, the patients showed a good level of epuration adequacy when total UF per session was at least 1.3 times the dry body weight. The total UF/body weight ratio thus seems to be an easy method in HF because of its greater ease of predictability and measurement, also when it is used independently of the Kt/V index.

Corticosteroids in IgA nephropathy: a randomised controlled trial.

BACKGROUND: IgA nephropathy is progressive in most cases and has no established therapy. In this randomised trial, we assessed the efficacy and safety of a 6-month course of steroids in this disorder. METHODS: Between July, 1987, and September, 1995, we enrolled 86 consecutive patients from seven renal units in Italy. Eligible patients had biopsy-proven IgA nephropathy, urine protein excretion of 1.0-3.5 g daily, and plasma creatinine concentrations of 133 micromol/L (1.5 mg/dL) or less. Patients were randomly assigned either supportive therapy alone or steroid treatment (intravenous methylprednisolone 1 g per day for 3 consecutive days at the beginning of months 1, 3, and 5, plus oral prednisone 0.5 mg/kg on alternate days for 6 months). The primary endpoint was deterioration in renal function defined as a 50% or 100% increase in plasma creatinine concentration from baseline. Analyses were by intention to treat. FINDINGS: Nine of 43 patients in the steroid group and 14 of 43 in the control group reached the primary endpoint (a 50% increase in plasma creatinine) by year 5 of follow-up (p<0.048). Factors influencing renal survival were vascular sclerosis (relative risk for 1-point increase in score 1.53, p=0.0347), female sex (0.22, p=0.0163), and steroid therapy (0.41, p=0.0439). All 43 patients assigned steroids completed the treatment without experiencing any important side-effects. INTERPRETATION: A 6-month course of steroid treatment protected against deterioration in renal function in IgA nephropathy with no notable adverse effects during follow-up. An increase in urinary protein excretion could be a marker indicating the need for a second course of steroid therapy.

On-line predilution hemofiltration versus ultrapure high-flux hemodialysis: a multicenter prospective study in 23 patients. Sardinian Collaborative Study Group of On-Line Hemofiltration.

The aims of the present prospective multicenter study were to assess the clinical tolerance and well being, the correlation between nPCr and Kt/V and the pretreatment beta 2-microglobulin level in patients sequentially treated with high-flux dialysis with ultrapure bicarbonate hemodialysis (HD; phase 1) and predilution hemofiltration (HF) with on-line prepared bicarbonate substitution fluid (phase II). The same monitor (Gambro AK 100 ULTRA) and membrane (polyamide) were used. Twenty-three patients, all in a stable clinical condition, entered the study. The treatment was targeted to an equilibrated Kt/V (eqKt/V) of 1.4 for HD and 1.0 for HF. No mortality or relevant morbidity were observed. The number of hypotensive episodes was 1.78 +/- 2.8 per patient and month during HD vs. 1.17 +/- 3.1 during HF (p = 0.003) and the number of the hypertensive episodes 1.28 +/- 2.8 during HD vs. 0.42 +/- 0.8 during HF (p = 0.04). Incidences of arrhythmia, muscular cramps and headache were significantly less frequent during HF. Interdialytic cramps, arthralgia and fatigue were also significantly less frequent during the HF period. The average beta 2-microglobulin level was 27.1 +/- 14.7 mg/dl at the start of the study, 22.9 +/- 4.9 mg/dl at the beginning of phase II and 22.4 +/- 4 mg/dl at the end of phase II (p = 0.01 compared to the start). A significant linear correlation between the normalized protein catabolic rate and eqKt/V was obtained faster during HD than during HF (45 vs. 120 days) indicating that HF affects the nutritional status with mechanisms different from HD. The present study is in agreement with the hypothesis that HF gives and adequate nutritional status with improved clinical stability and well being at a lower Kt/V compared to HD. Both therapies were efficient in controlling the pretreatment beta 2-microglobulin level.

Double phase parathyroid technetium-99m-MIBI scintigraphy to identify functional autonomy in secondary hyperparathyroidism.

UNLABELLED: Double-phase 99mTc-methoxyisobutylisonitrile (MIBI) parathyroid scintigraphy has been proposed to detect hyperplastic parathyroid tissue, but the clinical usefulness of this technique in secondary hyperparathyroidism is still debated. METHODS: Technetium-99m-MIBI parathyroid scintigraphy associated with parathyroid echography and [99mTc]pertechnetate thyroid scans were performed on 38 patients with chronic renal failure (CRF) and secondary hyperparathyroidism. In all patients, serum calcium, phosphorus, FT3, FT4, TSH, calcitonin and intact PTH (iPTH) were determined. Nine patients eventually underwent neck exploration and 28 parathyroid glands were removed. RESULTS: Thyroid diseases were excluded in all patients. Echography revealed parathyroid enlargement in 22/38 (58%) patients, while MIBI scintigraphy was positive in 28/38 (74%), including 5 ectopic glands. Mean serum iPTH concentration was significantly higher in MIBI-positive glands compared to MIBI-negative glands, but several discrepancies were observed in single patients. A significant positive correlation between serum iPTH and gland size was observed when MIBI-positive, but not MIBI-negative, parathyroids were considered. A paradoxical positive correlation between serum calcium and iPTH concentrations was found in MIBI-positive patients. CONCLUSION: Double-phase 99mTc-MIBI scintigraphy is positive in the majority of patients with uremic hyperparathyroidism. Comparison of scintigraphic data with morphological and functional data strongly suggests that 99mTc-MIBI scans do not reveal simple parathyroid enlargement but rather, identify the presence of hyperfunctioning (autonomous) parathyroid tissue suggestive of tertiary hyperparathyroidism.