[Maintenance and monitoring of water treatment system]. / Manutenzione e monitoraggio dell'impianto di trattamento dell'acqua di dialisi.

Water treatment systems must be submitted to maintenance, disinfections and monitoring periodically. The aim of this review is to analyze how these processes must complement each other in order to preserve the efficiency of the system and optimize the dialysis fluid quality. The correct working of the preparatory process (pre-treatment) and the final phase of depuration (reverse osmosis) of the system need a periodic preventive maintenance and the regular substitution of worn or exhausted components (i.e. the salt of softeners' brine tank, cartridge filters, activated carbon of carbon tanks) by a competent and trained staff. The membranes of reverse osmosis and the water distribution system, including dialysis machine connections, should be submitted to dis-infections at least monthly. For this purpose it is possible to use chemical and physical agents according to manufacturer' recommendations. Each dialysis unit should predispose a monitoring program designed to check the effectiveness of technical working, maintenance and disinfections and the achievement of chemical and microbiological standards taken as a reference. Generally, the correct composition of purified water is monitored by continuous measuring of conductivity, controlling bacteriological cultures and endotoxin levels (monthly) and checking water contaminants (every 6-12 months). During pre-treatment, water hardness (after softeners) and total chlorine (after chlorine tank) should be checked periodically. Recently the Italian Society of Nephrology has developed clinical guidelines for water and dialysis solutions aimed at suggesting rational procedures for production and monitoring of dialysis fluids. It is hopeful that the application of these guidelines will lead to a positive cultural change and to an improvement in dialysis fluid quality.

[The Dialysis Outcomes and Practice Patterns Study (DOPPS): results of the Italian cohort]. / Lo studio DOPPS (Dialysis Outcomes and Practice Patterns Study): risultati della coorte italiana.

BACKGROUND: The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective, longitudinal, observational study examining the relationship between dialysis unit practices and outcomes for hemodialysis (HD) patients in seven developed countries France, Germany, Italy, Spain, United Kingdom, Japan and the United States. Results of the DOPPS in Italy are the subject of this report. METHODS: A national representative sample of 20 dialysis units (21 in Germany) was randomly selected in each of the European DOPPS countries (Euro-DOPPS). In these units, the HD in-center patients were included on a facility census, and their survival rates continuously monitored. A representative sample of incident (269 in Italy, 1553 in the Euro-DOPPS) and prevalent (600 in Italy, 3038 in the Euro-DOPPS) patients was randomly selected from the census for more detailed longitudinal investigation with regard to medical history, laboratory values and hospital admission. RESULTS: Comparing the Italian and Euro-DOPPS cohorts we found comparable mean age for prevalent patients (61.4 vs. 59.5 yrs), but incident patients were older in Italy. Italian prevalent patients had less cardiovascular disease, more satisfactory nutritional status and more frequent use of native vascular access. These data were associated with a comparable mortality (15.7 vs. 16.3 deaths/100 patient yrs), but morbidity was lower in Italy. Kt/V levels were comparable in the two cohorts (1.32 vs. 1.37), but 35% of Italian patients showed a Kt/V below the recommended target. Moreover, hemoglobin levels were below 11 g/dL in 60% of Italian patients. CONCLUSIONS: The DOPPS results bring to light several positive aspects and the opportunity for further possible improvements for Italian patients, but at the same time highlight some critical points that could represent a risk for dialysis quality.

The role of underlying nephropathy in the progression of renal disease.

BACKGROUND: Disease-specific pathogenic mechanisms may be major determinants of the spontaneous rate of progression of chronic renal failure (CRF). To clarify the role of different underlying renal diseases, we examined the rate of CRF progression in 886 patients with chronic nephropathies. METHODS: Secondary analysis of two multicenter, prospective randomized trials: the Northern Italian Cooperative study (NIC) and the AIPRI study (ACE-Inhibition in Progressive Renal Insufficiency). Univariate and multivariate analyses of variance were used to select the covariates possibly related to CRF progression (estimated by means of the slope of the reciprocal of SCr against time), focusing on the contributory role of primary renal diseases. RESULTS: The overall rate of CRF progression was relatively low but there was a considerable difference in the slopes relating to the underlying nephropathy (particularly evident in the patients with chronic glomerulonephritis (CGN)). The median rate of CRF progression in both studies was more rapid in patients with polycystic kidney disease (PKD) and CGN than in those with other nephropathies. Multivariate analysis showed PKD as an independent predictor of the CRF progression rate only in the NIC Study (P < 0.0015); the selected variables in both studies predicted a variation of only 15-18% in the CRF progression rate. CONCLUSION: The underlying renal disease certainly plays a role in the natural history of CRF, but the variability of the CRF progression rates related to different renal diseases and between individuals with the same diagnosis underlines the need for caution in evaluating risk factors and predicting single patient outcomes.

Antiphospholipid (aPL) antibodies in end-stage renal disease.

Data are few and conflicting about the prevalence and risk factors for antiphospholipid (aPL) antibodies in end-stage renal disease (ESRD). We studied the prevalence, risk factors and clinical manifestations of lupus anticoagulant (LA) and anticardiolipin antibodies (aCL) among ESRD patients (chronic hemodialysis (HD) patients and kidney transplant recipients) and blood donors. LA was assessed in a large cohort (n=180) of patients by the activated partial thromboplastin time (aPTT), dilute Russel's viper venom test (dRVVT) and lupus anticoagulant-sensitive aPTT reagent (PTT-LA). IgM- and IgG-aCL were measured by a solid-phase enzyme-linked immunosorbent assay (ELISA) in 111 patients (61.5%). The prevalence of aPL was low but, it was higher in ESRD than blood donors (8.8% (16/180) vs. 0%, P=0.005); the frequency of aCL was also higher in ESRD than controls (10.8% (12/111) vs. 0%, P=0.002). LA was similar in the study and control groups (2.2% (4/180) vs. 0%, NS). Among HD patients and kidney allograft recipients there was no difference in LA (3.9% (4/101) vs. 0% (0/79), NS) and aCL frequency (18.6% (8/43) vs. 5.9% (4/68), NS). aPL was not associated with sex, age, time on HD, post-transplantation follow-up, ESRD etiology, thrombotic or hemorrhagic events, or type of HD membrane; however, these findings must be interpreted with caution, given the low frequency of aPL. In one HD patient LA activity was associated with multiple thrombosis of the access graft and native veins. In summary, the prevalence of aPL in ESRD is low but nevertheless higher than controls; LA does not appear to be related to membrane bio-incompatibility and it may be linked to vascular thrombosis; the lack of concordance between LA and aCL was apparent. Further studies are needed to clarify the issue of aPL in ESRD. LA testing should be incorporated into the diagnostic evaluation of recurrent thrombotic episodes in patients on HD.

GBV-C/HGV infection in end-stage renal disease: a serological and virological survey.

Patients with end-stage renal disease (ESRD) appear to be at high risk for GBV-C/HGV infection. This information has been obtained with virological techniques (RT-PCR) but few serological data exist. A prototype enzyme immunoassay has now been developed to detect antibodies against the putative envelope protein (E2) located on the surface of the GBV-C/HGV virion particle. We studied the prevalence of GBV-C/HGV infection, as detected by RT-PCR and anti-E2 GBV-C/HGV antibody, in a cohort of chronic dialysis patients (n=157) and renal transplant (RT) recipients (n=77); as a control group, 136 healthy blood donors were tested. The total prevalence of GBV-C/HGV in ESRD was 23% (54/234). The frequency of GBV-C/HGV viremia was 7.7% (18/234) in ESRD and 4.4% (3/68) among healthy blood donors; the prevalence of anti-E2 GBV-C/HGV was 15% (36/234) and 8.8% (12/136) in ESRD and controls, respectively. No relationship was seen between anti-E2 GBV-C/HGV antibody (or GBV-C/HGV viremia) and age, sex, time on renal replacement therapy, anti-HCV, HBsAg and transfusion requirement. No statistical association was observed between GBV-C/HGV and AST/ALT activity. Two of 54 GBV-C/HGV positive patients (3.7%) had raised ALT but were negative for HBV/HCV. In the majority of patients (35/36, 97%) the presence of anti-E2 GBV-C/HGV antibody was linked with the loss of GBV-C/HGV viremia from serum. In conclusion, GBV-C/HGV infection, as detected by RT-PCR and anti-E2 antibody, was common in ESRD, and the rate of infection was higher than in controls. No association was seen between GBV-C/HGV and various demographic or clinical factors. A small group of GBV-G/HGV positive patients tested negative for HBV/HCV and had raised ALT. In many patients exposed to GBV-C/HGV infection the virus was cleared. The clinical significance of GBV-C/HGV in ESRD remains controversial. Prospective studies with additional serological assays are in progress.

Intraplatelet serotonin (I5HT) in children with the hemolytic uremic syndrome.

I5HT levels were investigated in 14 children with Hemolytic Uremic Syndrome (HUS). Low levels of I5HT were demonstrated in all the children studied during the early phase of the disease, indicating reversible platelet aggregation and recirculation of degranulated platelets. Three months after the onset of HUS, only 2 children with a pathological picture of cortical necrosis and a mild degree of chronic renal failure had low I5HT levels. On the contrary, normal I5HT levels were present in the other children completely recovered from HUS and with a renal biopsy picture of thrombotic microangiopathy with predominant glomerular involvement. We conclude that normal values of I5HT, after the acute stage of HUS, are a good index of complete recovery from the disease. Further observations are required to assess the prognostic value of low I5HT levels in children with chronic renal failure secondary to HUS.

[Diet therapy in preventing the progression of chronic renal insufficiency]. / Terapia dietetica e prevenzione della progressione dell'insufficienza renale cronica.

The effect of a low protein diet (LPD) on the progression of chronic renal insufficiency (CRI) was investigated by reviewing the published studies. Only the trials of Rosman, Ihle and Locatelli fulfilled the main methodological criteria of being randomized, prospective and controlled. They involved 811 patients (671 evaluated: 338 on an LPD, 333 as controls) and had a mean follow-up of 29 months (range 18-48) for an estimated total of about 17,335 patient-months. The only trial whose results showed that LPD had a positive effect on the progression of chronic renal failure (CRF) was Ihle's study with the lowest weight (6.7%) and which involved the most severe CRF; effects limited to the patients with more advanced CRF were found in Roman's study, with an intermediate weight (41.8%); and little effect, if any, in Locatelli's trial accounting for 51.5% of patient-months, with less severe CRI. In conclusion, analysis of published randomized, prospective and controlled trials offers little or no evidence for the hypothesis that an LPD has a greater clinically significant effect on early CRI progression than a controlled protein diet, although a very low protein diet seems to postpone the need for dialysis.

[Rhabdomyolysis as a complication of Parkinson's disease]. / La rabdomiolisi come complicanza della Malattia di Parkinson.

BACKGROUND: Rhabdomyolysis is known as one of the possible causes of acute renal failure and can be triggered by different situations. In recent years, Parkinson's disease emerged as a condition that can be complicated by the development of rhabdomyolysis and consequently, in some cases, of acute renal failure. We report two cases of rhabdomyolysis, one of which complicated by an oligo-anuric renal failure, which occurred in patients affected by Parkinson's disease and admitted to our Division. METHODS AND RESULTS: The first case occurred in a 90-year-old Parkinsonian woman, under treatment with Levodopa-Benserazide and Bornaprine. She developed rhabdomyolysis (CPK 1746 U/L with MB isoenzyme 3.5 ng/ml, LDH 610 U/L, GOT 78 U/L) after she had been found lying on the floor, in a state of mental confusion, after 24 hours in which her relatives had not heard from her. During the first two days of hospitalization, the patient also had a fever (axillary temperature between 37 degrees C and 38 degrees C), accompanied by mild leukocytosis (WBC 13000/mm3) on entrance. The second case occurred in a 78-year-old Parkinsonian woman, under treatment with Levodopa-Carbidopa, Levodopa-Benserazide and Pramipexol. She developed a severe rhabdomyolysis (CPK 34800 U/L with MB isoenzyme 771 ng/ml, LDH 2133 U/L, GOT 785 U/L) complicated by acute renal failure with anuria, after two days characterized by several episodes of vomit and diarrhea. In the following days we learned that in the last 20 days before admission to hospital the patient had increased the dose of her anti-Parkinson therapy and was almost always disturbed by severe choreiform and dystonic movements. CONCLUSIONS: Regarding the first case, the clinical conditions in which the patient was found, the simultaneous presence of fever and leukocytosis and the absence of any reasonable explanation for a hypothetical fall to the floor induced us to think that this was a case of rhabdomyolysis in the context of an akinetic hyperthermic crisis. This is a syndrome that can develop in Parkinsonian patients after discontinuance or simply reduction of therapy with dopaminergic agents and is characterized also by rhabdomyolysis. The fact that the patient was living alone would confirm this hypothesis. On the other hand, the second case of rhabdomyolysis must probably be related to the severe choreiform and dystonic movements that the patient developed in the days just prior to admission. These movements were surely caused by the increase of the substitutive therapy with Levodopa by the patient herself. In conclusion, these two clinical cases, together with others previously reported by other Authors, show how the circumstances leading to the development of acute episodes of rhabdomyolysis in Parkinson's disease can be different and, at the same time, how these circumstances are always somehow related to the treatment of the basic disease with dopaminergic drugs.

[On-line hemodiafiltration with endogenous reinfusion (HFR). Experience of a Centre]. / Emodiafiltrazione con reinfusato on-line di liquido endogeno: esperienza di un Centro.

PURPOSE: Hemodiafiltration reinfusion (HFR) treatment is a dialysis technique that uses the endogenous reinfusion fluid and performs, simultaneously and separately, the three mechanisms of extracorporal depuration: diffusion, convection and adsorption. This study aimed to evaluate clinical and biochemical data of a group of six patients submitted to a dialytic HFR method for >6 months. METHODS: Six patients with a mean age of 53.8 +/- 11 yrs (five males, one female), treated with standard bicarbonate dialysis for a mean of 79.2 months, underwent HFR for a mean period of 14.9 +/- 6 months. Filters used were: a) in all patients polysulfone with 0.7 m2 of surface for the convection; b) polysulfone with 1.7 m2 in one patient, and modified cellulose with 2.0 m2 in five patients for diffusion; c) hydrophobic interaction resin and uncovered mineral carbon 240 mL for the adsorption. For all patients dialysis duration was 240 min and the amount of reinfusion fluid was 2.5 L/h as a mean, calculated according to blood flow and hematocrit (Hct), keeping a filtration fraction <22%. We evaluated, at different times, the following parameters: a) patient weight; b) Hct and erythropoietin (EPO) doses; c) parathyroid hormone (PTH); d) phosphatemia and doses of administered vitamin D; e) homocysteine (Hcy) and Beta2-microglobulin (Beta2-m); f) and albuminemia and transferrinemia as nutritional parameters. RESULTS: We observed an increase in Hct, with a reduction in EPO dosage, and an increase in albumin and transferrin levels, an improvement in nutritional indexes and in patient well-being. The mild increase in Hct with the same EPO dose was present in spite of a switch to intravenous (i.v.) administration from subcutaneous administration. There was low morbidity and only one hospitalization due to an infectious episode. CONCLUSIONS: HFR allows an amino acid saving and pro-inflammatory middle molecule removal, resulting in a better clinical situation for progressively critical uremic patients.

Mortality risk among hemodialysis patients receiving different vitamin D analogs.

Intravenous vitamin D is standard therapy for secondary hyperparathyroidism in hemodialysis (HD) patients. In for-profit dialysis clinics, mortality was higher for patients on calcitriol compared to paricalcitol. Doxercalciferol, a second vitamin D2 analog, is currently available. We assessed mortality associated with each vitamin D analog and with lack of vitamin D therapy in patients who began HD at Dialysis Clinic Inc. (DCI), a not-for-profit dialysis provider. During the 1999-2004 study period we studied 7731 patients (calcitriol: n=3212; paricalcitol: n=2087; doxercalciferol: n=2432). Median follow-up was 37 weeks. Mortality rates (deaths/100 patient-years) were identical in patients on doxercalciferol (15.4, 95% confidence interval (13.6-17.1)) and paricalcitol (15.3 (13.6-16.9)) and higher in patients on calcitriol (19.6 (18.2-21.1)) (P<0.0001). In all models mortality was similar for paricalcitol versus doxercalciferol (hazard ratios=1.0). In unadjusted models, mortality was lower in patients on doxercalciferol (0.80 (0.66, 0.96)) and paricalcitol (0.79 (0.68, 0.92)) versus calcitriol (P<0.05). In adjusted models, this difference was not statistically significant. In all models mortality was higher for patients who did not receive vitamin D versus those who did (1.2 (1.1-1.3)). Mortality in doxercalciferol- and paricalcitol-treated patients was virtually identical. Differences in survival between vitamin D2 and D3 may be smaller than previously reported.

Primary health care: a strategy for extending coverage to the unserved population.

PIP: This paper discusses the necessary implementation of the "primary health care strategy" in order that health services reach all of those presently unserved in Latin America. Primary health care deals with all health issues relating to integral development of the individual and the community. An interdisciplinary and intersectorial approach is needed to implement this strategy. Current obstacles to extending health services to deprived populations include: 1) lack of operational mechanisms to facilitate application of the policies, 2) the multiplicity of institutions which prevent coordination, 3) cultural barriers which are resistant to change, 4) insufficient human resource training and development, 5) lack of knowledge about appropriate technologies, 6) administrative deficiencies, and 7) financial constraints. The strategy's main thrust is directed against conditions that predetermine, trigger, or cause particular health problems. Activities of administration, information, planning and programming should emphasize: 1) community participation in planning, building, and preparing health services; 2) coordination of decisions by the community and the technical experts; 3) orientation, training, and logistical support; 4) daily service of health education; and 5) cooperation with teachers, social workers, community development workers, and malaria control personnel. Governments have begun reorienting their activities to meet these needs along with the aid of the World Health Organization and the Pan American Health Organization.^ieng

Controlled trials on low-protein diet: effects on chronic renal insufficiency progression.

The effect of a low-protein diet (LPD) on chronic renal insufficiency (CRI) progression was investigated by reviewing the published studies. Only three of these fulfilled the main methodological criteria of being randomized, prospective, and controlled: those of Rosman, Ihle and Locatelli. These trials involved 811 patients (671 evaluated: 338 on a LPD, 333 as controls) and had a mean follow-up of 29 months (range 18-48), for an estimated total of about 17,335 patient-months. The only trial whose results showed that LPD had a positive effect on chronic renal failure (CRF) progression was Ihle's study, with the lowest weight (6.7%) and involving the most severe CRF; effects limited to the patients with more advanced CRF were found in the Rosman study, with an intermediate weight (41.8%); and little effect, if any, was found in the Locatelli trial, accounting for 51.5% of patient-months, with less severe CRI. In conclusion, analysis of published randomized, prospective, and controlled trials offers little or no support for the hypothesis that a LPD has a clinically significant effect on the early CRI progression, although a very low protein diet seems to postpone the need for dialysis.

Atencion primaria de salud: estrategia para extender los servicios a la poblacion marginada. / Primary health care: strategy for extending services to the marginal populations

En la estrategia de atencion primaria de salud, las autoridades nacionales de salud, los organismos internacionales, los tecnicos, profesionales y politicos deben determinar la forma de actuar en los distintos niveles.Hasta el momento, se han dedicado esfuerzos para definir y caracterizar el proposito de cobertura universal, pero se ha prestado escasa atencion a la necessidad de definir el modo de alcanzarla. Al respecto, cabe senalar que entre los metodos y medios mas adecuados, no se trata de imponer a la comunidad lo que el sistema de salud decida en forma unilateteral por razones puramente tecnicas o administrativas, sino de imponer al sistema lo que la comunidad local, regional y nacional en realidad demanda, para satisfacer sus necesidades basicas de salud