[Canaud central venous catheters: 4-year experience]. / Cateteri venosi centrali di canaud: esperienza di oltre quattro anni.

BACKGROUND: The use of central venous catheters for permanent vascular access has become increasingly important because of the characteristics and the clinical problems of incident patients or patients already undergoing chronic hemodialysis. In this study a short and medium term evaluation was made of a double permanent central venous catheter positioned in the right internal jugular vein. The Canaud catheter was evaluated both from the point of view of practical use and for various technical and clinical problems. METHODS: During the observation period, July 1995 - September 1999, these catheters were used in 39 patients (mean age 72 years), 22 females and 17 males; 31% were diabetic patients and 46% were older than 75 years. Forty-five catheters were positioned with an average dwelltime of 347 days. RESULTS: Utilization was almost immediate and the resulting blood flow was suitable for all depurative techniques (blood flow more than 250 ml/min), with an average recirculation of 11.9% and an average resistance index of 0.54. Among the most serious complications during surgery a respiratory block was observed followed by the complete recovery of the patient. Some clinical complications were noted (5 venous thrombosis), as were some technical ones: 12% well as related to problems with the adapter, 24.3% to reversible thrombosis of the catheters occurred in 23 catheters in 22 patients. Infections. CONCLUSIONS: Overall Canaud catheters appear to represent a valid alternative to other more recent catheters for permanent vascular access. If necessary, they can be easily substituted due to the absence of a subcutaneous cuff.

[Permanent central venous catheters for dialysis. The situation in Piedmont-Aosta Valley]. / Cateteri venosi centrali a permanenza per dialisi. Realtà in Piemonte-Valle d'Aosta.

BACKGROUND: Permanent central venous catheters for hemodialysis have become increasingly important as vascular accesses for extracorporeal dialysis. The aim of this study was to evaluate the prevalence and various aspects of these catheters in the chronic dialysis population in Piedmont and Aosta Valley on 30-6-1998 using a multiple-choice questionnaire. METHODS: A total of 2389 patients were receiving chronic hemodialysis. Permanent central venous catheters were present in 6.2% of the population (149 patients), arteriovenous fistulas in 83.1%, vascular prostheses in 9.3% and temporary catheters in 1.4%. The site chosen for permanent catheters was the internal jugular vein in 88.6% of cases, the subclavian vein in 8.7% of cases and the femoral vein in 2.7% of cases. The double catheter is the most frequently used. In 76% of centres catheters are positioned by nephrologists. Thrombosis prophylaxis is performed in 98% of cases with heparin and the most frequently used disinfectant to dress the cutaneous exit is iodopovidone. RESULTS: This study highlights the important role played by permanent catheters. The double catheter was used in 64.4% of the entire population, confirming the greater efficiency of these catheters as reported in the literature. Operating autonomy is relative in 76.2% of centres where catheters are positioned by nephrologists who often use the collaboration of other specialists. CONCLUSIONS: The authors stress the need to reflect on the use of iodopovidone is to dress the cutaneous exit of catheters since this disinfectant is contraindicated by one of the largest manufacturers of silicone catheters owing to its harmful medium long-term effects.

[Temporary dialysis access in patients with acute renal failure. Protocols of the dialysis centers in the Piedmont and Valled'Aosta]. / Accessi temporanei per dialisi nei pazienti con IRA. Protocolli dei centri dialisi del Piemonte e della Valle d'Aosta.

BACKGROUND: A retrospective study was performed using a multiple-choice questionnaire in order to analyse the normal procedures and trends regarding the insertion and management of emergency dialysis access in patients with acute renal failure in 23 Centres in Piedment and the Aosta Valley, regions in the north of Italy with about 4.5 million inhabitants. METHODS: The observation period ran from January 1996 to July 1997. A questionnaire with 19 main questions and 90 possible multiple answers sent to 22 Centres for adults and the only pediatric centre in both regions. RESULTS: An analysis of the results showed that the most frequently used site in these regions is the subclavian vein (37.8%), followed by the internal jugular vein (32%), the femoral site (28.8%) and peritoneal catheter (1.4%); in pediatric patients, 5% used the femoral site, 10% the subclavian vein, 20% the internal jugular vein and 65% the peritoneal catheter. In 4 centres (18.2%), nephrologists do not position any type ofd access for acute renal failure. In 50% of centres, all doctors insert femoral catheters autonomously. CONCLUSIONS: Some choices, such as the subclavian route, are open to criticism and may perhaps be linked to customary procedures used by anesthetists and intensive care specialists. Some centres only have relative automomy for insertion, and lastly some types of catheters and techniques are not used. The peritoneal catheter has been abandoned by adult centres as an access in acute kidney failure patients.

[Permanent vascular catheters for extracorporeal dialysis. Preliminary study: Canaud and Tesio catheters]. / Catetere vascolare a permanenza per dialisi extracorporea. Studio preliminare: cateteri di Canaud e Tesio.

The use of alternative permanent vascular accesses has recently become increasingly common. The possibility of using the catheterization of central venous vessels has therefore been taken into consideration, in particular the internal jugular vein. During an observation period of 32 months the catheterization of the internal jugular vein (IJV) was used as a definitive access in 34 patients (12 M, 22 F; mean age 67.5, mean dialytic age 56 months in 18 patients, in 16 patients the insertion was by primary intention). A total of 44 IJV catheters were used, of which 18 Tesio and 26 Canaud. The authors examined the immediate complications following insertion and the episodes occurring during the observation period, including the problem of infection. The insertion of catheters was possible in all cases. In terms of catheter function, blood flow was adequate for the various purifying techniques. No severe complications were reported: gaseous embolism, pneumothorax, hemothorax, hemomediastinum. Infection was observed in 11 patients and 13 catheters, of which 70% were mainly provoked by Staphylococcus aureus and epidermidis. During the observation period there was a drop-out of 14 patients, 11 of whom died (3 following sepsis that failed to respond to antibiotic therapy). This preliminary experiment shows that permanent jugular catheters may be regarded as a valid access for hemodialytic treatment both in patients with severe problems of vascular access and for patients who present a short-term prognosis of dialysis and life expectancy at the time of starting hemodialysis.

Dialysis in the elderly: improvement of survival results in the eighties.

Analysis of long-term dialysis results is the cornerstone of renal replacement therapy evaluation. Elderly patients may be considered a crucial cohort, since subtle differences may be enhanced in a population of lower life expectancy. The aim of the study was an analysis, from the Piedmont Registry of Dialysis and Transplantation, of the results obtained in 1981-1992 (northern Italy, about 4,400,000 inhabitants, 21 dialysis centres, open acceptance since mid-1970s) in patients aged > or = 65 years (475 patients started treatment in 1981-1985, 1026 in 1986-1992). As a first treatment, during the 12 years considered acetate haemodialysis decreased sharply; bicarbonate haemodialysis is currently the standard treatment (68%). Peritoneal dialysis is stable (21%), and haemodiafiltration is increasing (8%). Shifts between treatments are frequent: 15% of elderly patients changed treatment at least once in 1991-1992. Nephroangiosclerosis/ischaemic renal disease, undefined causes and diabetes mellitus are the major causes of end-stage renal disease; 57.3% of patients have high risk conditions in addition to age. In this cohort of patients, mean age of new cases starting dialysis significantly increased in 1986-1992 (72.7 +/- 5.4 years) versus 1981-1985 (71.3 +/- 4.5; P < 0.001). Despite this, survival at 2 years increased significantly from 54.6% in the period 1981-1985 to 59% in the period 1986-1992 (P < 0.05). Even in an ageing dialysis population, therefore, choice of an open dialysis system with easy changes among treatments allowed improvement of survival results; further technical advances may help in maintaining present trends.

[Instantaneous clearances: standard heparin versus low molecular weight heparin]. / Clearances istantanee: eparina standard verso eparine a basso peso molecolare.

Standard heparin is still considered as a reference point for anticoagulation in CEC, although its use is not totally devoid of long-term and short term side effects, considering the risk of hemorrhage that patients undergo during dialysis. Numerous attempts have been made in the search for an alternative anticoagulating method. The recent discovery that low molecular weight fractions (LMWH) of standard heparin (UFH) assure the same antithrombotic effect but with a minor anticoagulating action, points to such a drug as an interesting alternative to the traditional use of heparin during dialysis. Our present task is to evaluate the purifying efficiency of different cuprophan and synthetic membranes with two LMWH and UFH, measuring the instantaneous ureic clearance of different dialysers at the start and end of each dialysis. N. 43 chronic patients were examined whilst undergoing different methods of treatment; using 12 different kinds of membrane, for a total of 22 filters. Every patient underwent a dialysis using each kind of heparin at least once, for a total of 189 dialysis. Neither the initial nor the final ureic clearances, nor the percentage of decreasing had changed by using different types of heparin and membranes with diverse thrombogenicity and ultrafiltration capacities. We may conclude from the results of the tests that the purifying efficiency of small molecules, judging from the istantaneous clearances, do not significant results compared to UFH.

[Renal insufficiency due to cholesterol embolism. 4 cases]. / Insufficienza renale da embolia colesterinica. Quattro casi.

Atheroembolic disease is a complication of atheromatous disease and is quite often misunderstood. A precise diagnosis can be made difficult, by the lack of specific tests. The first case, in which we identified this disease, resulted from a bladder biopsy, in the instance of a patient with a suspected carcinoma. The experience, with this initial patient, led us to identification of a further 3 cases, within our previous 2 years case histories. One must consider the possibility of atheroembolic disease during the differential diagnosis of acute renal failure in geriatric patients, given the serious prognosis.

[Weekly dialysis integrated with low-protein diet and essential amino acids. Preliminary data]. / Dialisi monosettimanale integrata con dieta ipoproteica e aminoacidi essenziali. Dati preliminari.

The possibility of applying a once-a-week dialysis programme supplemented with hypoproteic diet as an adequate technique for starting the uraemic patient on dialysis is examined. Thirteen patients have been so treated, 7 of them currently under treatment for a global period of observation of 46 months. At the moment dialysis began, mean glomerular filtrate was 5.14 ml/min. Once-a-week dialytic treatment with bicarbonate dialysis was associated with a hypoproteic diet of 0.5 g/kg/die of proteins, supplemented with essential amino acids. This treatment showed excellent dialytic tolerance, the values of dialysis start blood nitrogen were lower than 200 mg/dl and dialytic efficiency was compatible with a Kt/v greater than 1.1. There was no observation of any subjective or objective symptomatology that could be related to dialytic inadequacy. Taken as a whole these results make it possible to state that this type of approach permits a gradual start to dialysis and deserves further study.

[Home dialysis. Review of clinical organizational and management problems encountered in more than 6 years of activity]. / La dialisi domiciliare. Rassegna sintetica dei problemi clinici, organizzativi e gestionali relativi all'esperienza di oltre 6 anni di attività.

Together with other forms of self-dialysis (including limited assistance and self-service), home dialysis keeps down cost to much lower levels than those ruling within the hospital. Self-management, which is a common factor of various types of extra-hospital dialysis, also enables the patient to fit in better to society and, in the majority of cases, offers complete working rehabilitation by way of deeper consciousness of his disease and of the various treatments for it. Personal experience of home dialysis covering 6 years activity in the sector is reported. 91 patients have been trained in self-management and 65 of these have already been sent home or are about to be. The most important problems tackled over this period are examined and the experience analysed. Particular reference is made to clinical, organizational and management problems. The paper thus forms a practical guide for those wishing to direct their efforts towards a home dialysis programme.

[Acute renal failure and acute abdomen]. / Insufficienza renale acuta ed addome acuto

A series of patients with acute renal failure (ARF) and acute abdomen collected by the St. John the Baptist Hospital's Nephrology and Dialysis Division over the period 1970-75 is examined. A high rate of mortality was noted, due to causes that were mostly independent of ARF Death was often related to failure to resolve acute abdomen. The progression of ARF appeared to be related to that of the abdominal affection with prompt resolution of the latter. These findings suggest that constriction of the afferent arteriole may offer a partial, functional basis for ARF with the corollary that it has a good chance of being reversed, even after protracted periods of anuria. Renal complications associated with disseminated or localised intravascular coagulation appear to be rare. Treatment was best directed to early and frequent dialysis, with surgical resolution whenever indicated, irrespective of the presence of ARF.

[Use of coil negative pressure in the kidney]. / Utilizzazione della pressione negativa nei reni a rotolo

A sealed compartment recycling system has been created for use with Extracorporeal commercial filters in order to exploit the negative pressure of the dialysate for purposes of ultrafiltration. The results of in vivo and in vitro tests regarding ultrafiltration and dialysates of urea, creatinine, Hipaque I125 and vit. B12 Co57 are reported. The tests highlighted improved dehydration characteristics in the system compared with the traditional coil technique, while the dialysates of small and medium molecules showed no decrease. The system can profitably be used as an alternative to the open compartment coil system and is particularly interesting because it can be combined with monitors which provide exclusively for the use of closed circuit dialysate instruments.