[The role of the nephrologist in the management of vascular access for hemodialysis]. / Dalla Mailing List Soci SIN (ML-SIN). Ruolo del nefrologo nella gestione degli accessi vascolari per emodialisi.

The role of the nephrologist in the management of vascular access for hemodialysis has recently been the subject of intense debate on the SIN mailing list. In the present issue, the topic is commented on in view of some literature data. The DOPPS Study has provided information about vascular access practice patterns in different countries. The use of arteriovenous fistula (AVF) is much more frequent in Europe than in the USA (80% vs 24%), where grafts are the most frequent vascular access (58%). In Europe, AVF is most common in Italy (90%), where nephrologists are largely in charge of vascular access surgery. AVF survival has been demonstrated to be longer than graft survival. Vascular access is also associated with patient survival, as the mortality and hospitalization risks are higher in patients with central venous catheters (CVC) and lower in those with AVF. Independent of who is in charge of vascular access surgery, nephrologists play a pivotal role as the main actors of patient care. Nephrological follow-up before dialysis initiation has been independently associated with permanent vascular access and improved patient survival. The Canadian experience, where CVC use is high due to the lag between patient referral and vascular access surgery, has taught that it is mandatory to give vascular access surgery sufficient room and time. In this respect, the nephrologist has an important role to play in the organization of vascular access surgery to fulfill patients' needs in real time.

[Ethical issues in living renal transplantation]. / Problemi etici nel trapianto renale da vivente.

The paper by EA Friedman and AL Friedman, recently published in Kidney International, advocating legislation to govern and regulate kidney sales, stimulated a heated discussion on the Mailing List of the Italian Society of Nephrology (ML-SIN). The aim of this article is to review the main elements of the issue raised by the authors and summarize the messages on this topic. It is known that the steady increase in the number of patients with end-stage renal disease treated by dialysis outpaces the available kidney donors: the approach proposed by EA and AL Friedman to expand the pool of kidney donors is to legalize payment of a fair market price to donors. According to the authors, the case for legalizing kidney trade hinges on the right of individuals to control their body parts. The participants in the discussion on the ML-SIN generally took a critical stance against this proposal, even if they expressed their opinions more or less clearly and used different arguments. The most widely held view among the nephrologists of the ML-SIN is that trade of organs for transplant is unethical and that it is impractical to propose the legislative hypothesis suggested by Friedman in Italy because of the characteristics of its social, cultural and healthcare systems, and because it would necessitate review of all related current laws.

[From the Mailing List SIN: professional risks for the nephrologists: clinical risk and risk management]. / Dalla Mailing-List soci SIN (ML-SIN). Eventi indesiderati nei Centri Dialisi: Rischio clinico e risk management nel sistema sanitario.

An extensive debate on bacteraemias due to aquatic bacteria has recently developed in the Mailing List SIN. This topic was analyzed in two previous issues where the epidemics observed in two Dialysis Centers have been presented and discussed. The two experiences had in common the difficulty in identifying the source of contamination in industrial products commercialized as ''sterile''. In one case, the source of the epidemic could not be identified, in the other one it was discovered only incidentally thanks to a notice of the supplier company of the contaminated material. This underlines the importance of defining specific operating protocols in case of hospital epidemics and stresses the issues related to the professional risk and the potential legal implications.

[From the Mailing List SIN: Epidemic of infections caused by 'aquatic' bacteria in patients undergoing hemodialysis via central venous catheters]. / Dalla Mailing-List soci SIN (ML-SIN). Epidemia di infezioni causate da batteri 'acquatici' in pazienti emodializzati tramite cateteri venosi centrali.

UNLABELLED: Bacteremia due to central venous catheter (CVC) infection is the most frequent complication of CVC use as vascular access for hemodialysis (HD). We report a case of an epidemic of CVC infections caused by 3 strains of unusual bacteria: Ralstonia pickettii (Rp), Leifsonia xyli/Leifsonia aquatica (Lxa), Tsuckamurella strandjordae (Ts). From 20/8/01 to 30/9/01, 23 of 35 patients dialyzed via CVCs experienced intra-HD pyrogenic reactions. Their hemocultures were positive for: Rp (14 pts), Lxa (3 pts), Rp+Lxa (5 pts) and Rp+Ts (1 pt). The hemocultures of 12/35 asymptomatic pts were positive for: Rp 2 pts, Lxa 2 pts, Rp+Lxa 2 pts, Ts 1 pt, Rp+Ts 1 pt. The epidemiological and microbiological analyses of environmental samples failed to identify the source of the epidemic. Actions taken were: a) replacement of the batches of disposable materials; b) removal of CVCs in cases where possible to prepare a different access; c) treatment of the infections with intra-CVC antibiotic lock therapy. No relapses were recorded until April 2002, when 8 pts had again pyrogenic reactions due to Rp. After quick substitution of the CVC and repetitions of the action a), no relapses of pyrogenic reactions were observed. CONCLUSIONS: 1) given the characteristics of Rp, Lxa and Ts, saprophytes of moist environments, the most plausible source of the epidemic was a low-charge contaminated solution that was not identified due to low sensitivity of environmental sample culturing methods; 2) antibiotic lock therapy is a viable option for the conservative treatment of CVC infections.

[From the Mailing List SIN: Therapy and prevention of peritoneal sclerosis]. / Dalla Mailing-List soci SIN (ML-SIN). La sclerosi peritoneale: terapia e prevenzione.

Recently, in the Mailing List of the Italian Society of Nephrology (ML-SIN), a message asking for opinions on the diagnosis and treatment of peritoneal sclerosis gave rise to an extensive debate on this interesting clinical topic. The discussion evidenced significant differences both in the reported onset of clinical manifestations, emphasizing the difficulty in obtaining a definite early diagnosis, and in therapy approaches. Occasionally, this is limited to medical treatment, but surgery, although burdened with elevated complexity and high mortality rates due to post-operative complications, is usually advocated for intestinal obstruction. This is the second issue reserved for the review of the ML-SIN concerning this topic, following that dedicated to definition, etiology, pathology and clinical characteristics. In this section, two expert colleagues complete the analysis of the different aspects of peritoneal sclerosis, discussing the therapy and the prevention of this serious complication of peritoneal dialysis.

[From the Mailing List SIN: peritoneal sclerosis]. / Dalla Mailing-List soci SIN (ML-SIN): la sclerosi peritoneale.

In the course of previous months, in the Mailing List of the Italian Society of Nephrology (ML-SIN), a message asking for opinions on the diagnosis and treatment of peritoneal sclerosis, gave rise to an extensive debate concerning this clinically interesting topic. The discussion evidenced significant differences both in the reported onset of clinical manifestations, emphasizing the difficulty in obtaining a definite early diagnosis, and in therapy approaches. This is sometimes limited to medical treatment, but surgery, although burdened with elevated complexity and a high mortality rate, mainly due to post-operative complications, is usually advocated for intestinal obstruction. In this issue of the review dedicated to the ML-SIN, two expert colleagues will analyze the different aspects of peritoneal sclerosis. The argument is developed in two sections: the first section is dedicated to the discussion of definition, etiology, pathology and clinical characteristics of this serious complication in peritoneal dialysis (PD).

[On the mailing list: use of acyclovir in patients on hemodialysis]. / Sulla Mailing List: uso dell'acyclovir nei pazienti dializzati.

In the SIN Mailing List a message published in May 2004 gave rise to an interesting debate as to the use and dosage of acyclovir in dialysis patients for the treatment of varicella-zoster infection, considering the side effects (mainly neurological) reported in patients affected by renal insufficiency. In this issue, we summarised the main pharmacological characteristics of acyclovir and the clinical indications for using this drug. Finally, we analysed the literature data concerning acyclovir side effects in the setting of renal insufficiency. As they indicate that acyclovir-induced neurotoxicity in renal insufficiency patients may be unpredictable even at reduced dosages, this should discourage the use of acyclovir when severe renal insufficiency is present, unless severe herpes infection is present and after evaluating carefully the risk-benefit. In this case, the patient has to be kept under strict medical control to detect the acyclovir-induced side effects early. The use of new antiviral drugs, such as famciclovir or brivudine, to treat herpes virus infections in patients with renal insufficiency is currently not supported by sufficient data for a critical review.

[From the Mailing List of the Italian Society of Nephrology: use of isolation rooms for HBV-positive patients in dialysis--part two]. / Dalla Mailing List SIN: utilizzo di sale contumaciali per pazienti HBV positivi in dialisi (seconda parte).

In the course of recent months, on the mailing list of the Italian Society of Nephrology (ML-SIN), a message asking for opinions on preventative measures for HBsAg patients has stimulated an extensive debate, in particular on the use of separate dialysis rooms. The discussion evidenced significant differences in the procedures adopted, not only between dialysis units, but also in regional health systems' directives. This emphasizes the necessity in dealing carefully with this problem, taking into account the scientific evidence of the infectious risk and epidemiological profile of hepatitis B virus (HBV) in dialysis patients. Moreover, potential solutions must be considered in terms of their effective cost benefit ratio. To complete the previous article, which examined the question from the viewpoint of an expert nephrologist, this issue of the review dedicated to the ML-SIN reports the opinion of an infectious diseases specialist, identified for its scientific contribution to this specific discussion.

[From the Mailing List of the Italian Society of Nephrology: hepatitis B prevention in dialysis units]. / Dalla Mailing List SIN: utilizzo di sale contumaciali per pazienti HBV positivi in dialisi.

The Mailing List SociSIN (ML-SIN) continues to develop, in addition to more experienced organizational topics, the discussion on clinical arguments. In the course of previous months, a message asking the opinions of expert Colleagues concerning preventative measures for HBsAg positive patients, in particular the use of separate rooms, has stimulated an extensive debate on this topic. This issue of the review is dedicated to the ML-SIN. It presents a short introduction dedicated to the definition of this problem. Thereafter, the messages regarding this argument are summarized, and, finally, the opinion of two experts regarding this matter is reported, experts identified as holding in account the importance of it international scientific contribution in on this specific discussion.

[From the Mailing List of the Italian Society of Nephrology: Pharmacological therapy and plasma exchange in the treatment of HCV-associated cryoglobulinemia]. / Sulla Mailing List di maggio: ruolo della terapia farmacologica e della plasmaferesi nel trattamento della crioglobulinemia associata al virus dell'Epatite C.

The Mailing List SociSIN (ML-SIN) is beginning to develop, beside more experienced organisational topics, there is also some discussion on clinical topics. During the month of May, some messages requesting the opinion of experienced Colleagues on the use of plasma exchange in the cryoglobulinaemia correlated with HCV have risen an interesting debate on this argument. This issue of the review dedicated to the ML-SIN presents a short introduction dedicated to the definition, the main characteristics and the therapeutic bases of the cryoglobulinaemia associated to HCV. The messages on this topic are then summarised and, finally, the opinion of an expert on the matter is reported. The expert is chosen on the basis of the importance of his international scientific contribution to this particular topic.

[The activity of the Soci SIN Mailing List (ML-SIN): an update]. / aggiornamento sull'attività della Mailing List Soci SIN (ML-SIN).

The Soci SIN Mailing List (ML-SIN) is the automatic on-line moderated discussion group for nephrology professionals of the Italian Society of Nephrology, which regularly operates since October 2000. The new publishing initiative of the Giornale Italiano di Nefrologia reserves to the ML-SIN a special survey in which the most discussed topics will be summarised and commented. This paper presents an update of the last six months (October 2003 - march 2004) of ML-SIN activity. The number of ML-SIN members has increased from 525 to 603 (+15%), thus confirming an increasing interest in the ML-SIN as discussion instrument and reliable source of professional advice for the Italian nephrological community. The number of messages received and accepted was 1024, for the most part (49%) related to general or organizational topics (i.e., regulatory information, meeting announcements and management issues) and only 51% to scientific debate. Some of the topics are discussed in detail, e.g. the proposal for a retrospective study on cholesterol crystal embolism and the analysis of dialysis treatment reimbursement rates by the Health System Financial Organization.