Peritoneal Dialysis in Italy: the 8th GPDP-SIN Census 2022 - 2nd Part: the Centers.

Objectives. The results are presented of the 8th National Census (Cs-22) of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology relating to the characteristics of the Centers in Italy which used PD in 2022. Materials and methods. The 227 non-pediatric centers which used Peritoneal Dialysis (PD) in 2022 took part. The data requested were sent in aggregate form. For the first time, the resources available and training were investigated as well as home visits. The Centers have been divided into Quartiles according to the number of prevalent PD patients at 31/12/2022. Results. Centers with a smaller PD program (<9 pts) are characterized by 1. smaller overall size - 2. fewer personnel (doctors/nurses) dedicated to PD - 3. greater recourse to external personnel for training - 4. Less incremental prescription and evaluation of peritoneal permeability - 5. higher drop-out to HD in particular for choice/impossibility to continue and for adequacy/catheter-related issues. A lower peritonitis rate was recorded in Centers with a more extensive PD program (≥25 pts). Home visits are carried out regularly by a small minority of Centers. Conclusions. The analysis shows an association between size of Center PD program and available resources, PD modality and outcome.

Role of the Opinions of the Nephrologist and Structural Factors in Dialysis Modality Selection. Results of a Peritoneal Dialysis Study Group Questionnaire.

Background. The use of PD depends on economic, structural and organizational factors. The nephrologist's opinion is that peritoneal dialysis is less used than it shold be. In Italy, PD is not carried out in private Centers, but neither is it in around one third of Public Centers. The aim of this study was to investigate the opinions of nephrologists on PD in Public Centers only, thereby nullifying the influence of the economic factors. Materials and Methods. The investigation was carried out by means of an online questionnaire (Qs) via mail, and during meetings and Congresses in 2006-07. The Qs investigated the characteristics of the Centers, the nephrologists interviewed, and opinions on the various aspects of the choice of Renal Replacement Therapy Renal Replacement Therapy (RRT) (26 questions). Responses were received from 454 nephrologists in 270 public Centers. Among these, 205 centers (370 Qs) report PD (PD-YES), 36 (42 Qs) do not (PD-NO) and 29 (42 Qs) do not use it but send patients selected for PD to other Centers (PD-TRANSF). Results. The PD-NO and PD-TRANSF Centers are significantly smaller, with greater availability of beds. In the PD-YES Centers the presence of a pre-dialysis pathway, early referral and nurses dedicated solely to PD are associated with a higher use of PD. The nephrologists in the PD-NO Centers rate PD more negatively in terms of both clinical and non-clinical factors. The belief that more than 40% of patients can do either PD or HD differs among the nephrologists in the PD-YES (74.3%), PD-TRANSF (45.2%) and PD-NO (28.6%) Centers. Likewise, the belief that PD can be used as a first treatment in more than 30% of cases differs among the nephrologists in PD-YES (49.2%), PD-TRANSF (33.3%) and PD-NO (14.3%) Centers. Conclusions. The use of PD in Public Centers is conditioned by both structural and organizational factors, and by the opinions of nephrologists on the use and effectiveness of the technique.

Peritoneal dialysis discontinuation: to the root of the problem.

As the global burden of chronic kidney disease continues to increase, the use of peritoneal dialysis is often advocated as the preferred initial dialysis modality. Observational studies suggest a survival advantage for peritoneal dialysis over hemodialysis for the initial 2-3 years of dialysis. Peritoneal dialysis has been associated with better graft survival after kidney transplantation and has a reduced cost burden compared to hemodialysis. However, several medical and non-medical reasons may limit access to peritoneal dialysis, and less than 20% of patients with end-stage kidney disease are treated with peritoneal dialysis worldwide. In this narrative review, we sought to summarize the recent medical literature on risk factors for peritoneal dialysis discontinuation, distinguishing the early and the late phase after peritoneal dialysis initiation. Although the definition of clinically relevant outcomes varies among studies, we observed that center size, older age, and the presence of many comorbidities are risk factors associated with peritoneal dialysis discontinuation, regardless of the phase after peritoneal dialysis initiation. On the contrary, poor technique training and late referral to nephrology care, as opposed to the need for a caregiver, patient burnout and frequent hospitalizations, are related to early and late peritoneal dialysis drop-out, respectively. The aim of the review is to provide an overview of the most relevant parameters to be considered when advising patients in the selection of the most appropriate dialysis modality and in the clinical management of peritoneal dialysis patients. In addition, we wish to provide the readers with a critical appraisal of current literature and a call for a consensus on the definition of clinically relevant outcomes in peritoneal dialysis to better address patients' needs.

Peritoneal Dialysis in Italy: the 8th GPDP-SIN census 2022

Objectives. The results are reported here of the 8th National Census (Cs-22) of Peritoneal Dialysis in Italy, carried out in 2022-23 by the Italian Society of Nephrology's Peritoneal Dialysis Project Group and relating to 2022. Methods. The Census was conducted in the 227 non pediatric centers which performed Peritoneal Dialysis (PD) in 2022. The results have been compared with the previous Censuses carried out since 2005. Results. Incidence: in 2022, 1350 patients (CAPD=52.1%) started on PD (1st treatment for ESRD). PD was started incrementally by 35.3% in 136 Centers. The catheter was placed exclusively by a Nephrologist in 17.0% of known cases. Prevalence: there were 4152 (CAPD=43.4%) patients on PD on 31/12/2022, with 21.1% of prevalent patients on assisted PD (family member caregiver: 86.3%). Out: in 2022 the PD drop-out rate (ep/100 pt-yrs) was: 11.7 to HD; 10.1 death, down; 7.5 Tx. The main cause of transfer to HD remains peritonitis (23.5%), although its reduction over the years is confirmed (Cs-05: 37.9%). Peritonitis/EPS: the incidence of peritonitis in 2022 was 0.176 ep/pt-yr (696 episodes). The incidence of new cases of EPS fell in 2021-22 (7 cases). Other results: the number of Centers using 3.86% for the peritoneal equilibration test (PET) (57.7%) increased. PD for heart failure continues to be used in 44 Centers (66 pts). Conclusions. Cs-22 confirms PD's good results in Italy.

[Peritoneal Dialysis in Italy: the 7th GSDP-SIN census 2019].

Objectives: Analysis of the results of the 7th National Census (Cs-19) of Peritoneal Dialysis in Italy, conducted in 2020-21 by the Peritoneal Dialysis Project Group of the Italian Society of Nephrology, for the year 2019. Materials and methods: The data was initially collected using specially designed software, which after entering the data of individual patients allows the aggregate extraction of the necessary information. The difficulties due to the COVID pandemic made it necessary to also use the traditional on-line questionnaire used previously. Of the 237 Centers envisaged, 198 responded, of which 177 with complete data for HD also in 2016. Results: Overall incidence and prevalence (31/12/2019) were respectively 1,363 (CAPD/APD = 741/622) and 3,922 (CAPD/APD = 1,857 / 2,065) patients. The percentage incidence and prevalence (177 Centers) decreased compared to 2016, respectively, from 23.8% to 22.1% and from 17.3% to 16.6%. 31.4% started PD incrementally in 60.3% of the Centers. The catheter is placed by the Nephrologist alone in 19.7%. Assisted PD is used by 24.5% of the prevalent patients, mostly (83.8%) by a family member. In 2019, the exit from PD (ep/100 years-pts: 11.6 in HD; 8.9 death; 6.0 Tx) is decreasing for all causes. The main cause of transfer to HD remains peritonitis (26.8%). The incidence of peritonitis in 2019 dropped further to 0.190 ep/year-pts as well as the incidence of new cases of EPS (0.103 ep/100 years-pts). Conclusions: The Cs-19 confirms the good results of the DP in Italy.

SARS-CoV-2 infection in dialysis and kidney transplant patients: immunological and serological response.

BACKGROUND: Dialysis and kidney transplant patients with moderate-severe COVID-19 have a high mortality rate, around 30%, that is similar in the two populations, despite differences in their baseline characteristics. In these groups, the immunology of the disease has been poorly explored. METHODS: Thirty-two patients on dialysis or with kidney transplant and SARS-CoV-2 infection requiring hospitalization (COV group) were included in our study. Lymphocyte subsets, dendritic cell (DC) counts and monocyte activation were studied. SARS-CoV-2 anti-spike/anti-nucleocapsid were monitored, and baseline cytokines and chemokines were measured in 10 patients. RESULTS: The COV group, compared to healthy subjects and uninfected dialysis/kidney transplant controls, showed lower numbers of CD4 + and CD8 + T cells, Natural-Killer (NK), B cells, plasmacytoid and myeloid DCs, while the proportion of terminally differentiated B-cells was increased. IL6, IL10, IFN-α and chemokines involved in monocyte and neutrophil recruitment were higher in the COV group, compared to uninfected dialysis/kidney transplant controls. Patients with severe disease had lower CD4 + , CD8 + and B-cell counts and lower monocyte HLA-DR expression. Of note, when comparing dialysis and kidney transplant patients with COVID-19, the latter group presented lower NK and pDC counts and monocyte HLA-DR expression. Up to 60 days after symptom onset, kidney transplant recipients showed lower levels of anti-spike antibodies compared to dialysis patients. CONCLUSIONS: During SARS-CoV-2 infection, dialysis and kidney transplant patients manifest immunophenotype abnormalities; these are similar in the two groups, however kidney transplant recipients show more profound alterations of the innate immune system and lower anti-spike antibody response.

Ten-year experience of an outpatient clinic for CKD-5 patients with multidisciplinary team and educational support.

PURPOSE: To analyze the results of an outpatient clinic with a multidisciplinary team and educational support for patients with late-stage CKD (lsCKD), to check its possible effect on their outcomes. METHODS: Longitudinal cohort study on patients followed up in the MaReA (Malattia Renale Avanzata = CKD5) outpatient clinic at ASST Spedali Civili of Brescia from 2005 to 2015 for at least six months. Trajectory of renal function over time has been evaluated only in those patients with at least four estimations of eGFR before referring to MaReA. RESULTS: Seven hundred and six patients were enrolled, their mean age was 72 ± 14 years, 59% were males. At the end of the study, 147 (21%) were still on MaReA, 240 (34%) on dialysis, 92 (13%) on very low-protein diet (VLPDs), 13 (2%) on pre-hemodialysis clinic, 23 (3%) improved renal function, 10 (1%) transplanted, 62 (9%) transferred/lost to follow-up, and 119 (17%) died. Optimal dialysis start (defined as start with definitive dialysis access, as an out-patient and without lsCKD complications) occurred in 180/240 (75%) patients. The results showed a slower eGFR decrease during MaReA follow-up compared to previous renal follow-up: - 2.0 vs. - 4.0 mL/min/1.73 m2 BSA/year (p < 0.05), corresponding to a median delay of 17.7 months in dialysis start in reference to our policy in starting dialysis. The patient cumulative survival was 75% after 24 months and 25% after 70. LIMITATIONS: (1) lack of a control group, (2) one-center-study, (3) about all patients were Caucasians. CONCLUSION: The follow-up of lsCKD patients on MaReA is associated with an optimal and delayed initiation of dialysis.

[Peritoneal Dialysis in Italy: the 6th GSDP-SIN census 2016].

OBJECTIVES: We report here the results of the 6th National Census (Cs-16) of Peritoneal Dialysis in Italy, carried out in 2017-18 by the Italian Society of Nephrology's Peritoneal Dialysis Study Group and relating to 2016. METHODS: The Census was conducted using an on-line questionnaire administered to the 237 non pediatric centers which did perform Peritoneal Dialysis (PD) in 2016. The results have been compared with the previous Censuses carried out since 2005. RESULTS: Incidence: In 2016, 1,595 patients (CAPD=56.1%) started on PD (1st treatment for ESRD) and 4,607 on hemodialysis (HD). PD was started incrementally by 32.5% in 144 Centers. 15.6% were late referrals, and 5.1% began within 48-72 hours of insertion. The catheter was positioned exclusively by a Nephrologist in 24.3% of cases. Prevalence: Patients on PD on 31/12/2016 were 4,607 (CAPD=46.6%), with 22.2% of prevalent patients on assisted PD (family member caregiver: 80.5%). Out: In 2016, PD dropout rate (ep/100 pt-yrs: 12.5 to HD; 11.8 death; 7.0 Tx) has not changed. The main cause of transfer to HD remains peritonitis (23.8%), although it is still decreasing (Cs-05: 37.9%). Peritonitis/EPS: The incidence of peritonitis in 2016 was 0.211 ep/pt-yr (939 episodes). The incidence of new cases of EPS in 2015-16 is diminishing too (16 cases=0.176 ep/100 pt-yrs). Other results: In 2016 the number of Centers using 3.86% for the peritoneal equilibration test (PET) (49.8%) increased, and the Centers carrying out home visits diminished (51.5%). CONCLUSIONS: Cs-16 confirms that PD in Italy is having good results.

Incremental dialysis in ESRD: systematic review and meta-analysis.

BACKGROUND: Incremental dialysis may preserve residual renal function and improve survival in comparison with full-dose dialysis; however, available evidence is limited. We therefore compared all-cause mortality and residual kidney function (RKF) loss in incremental and full-dose dialysis and time to full-dose dialysis in incremental hemodialysis (IHD) and incremental peritoneal dialysis (IPD). METHODS: We performed a systematic review and meta-analysis of cohort studies of adults with ESRD starting IHD and IPD. We identified in PubMed and Web of Science database all cohort studies evaluating incremental dialysis evaluating three outcomes: all-cause mortality, RKF loss, time to full dialysis. IPD was defined as < 3 daily dwells in Continuous Ambulatory Peritoneal Dialysis and < 5 sessions per week in Automated Peritoneal Dialysis, while IHD was defined as < 3 HD sessions per week. RESULTS: 22 studies (75,292 participants), 15 in HD and 7 in PD, were analyzed. Mean age at dialysis start was 62 and 57 years in IHD and IPD subjects, respectively. When compared to full dose, incremental dialysis (IHD or IPD) had an overall mortality risk of 1.14 [95% CI 0.85-1.52] with high heterogeneity among studies (I2 86%, P < 0.001), and lower mean RKF loss (- 0.58 ml/min/months, 95% CI 0.16-1.01, P = 0.007). Overall, time to full-dose dialysis was 12.1 months (95% CI 9.8-14.3) with no difference between IHD and IPD (P = 0.217). CONCLUSIONS: Incremental dialysis allows longer preservation of RKF thus deferring full-dose dialysis, by about 1 year in HD and PD, with no increase in mortality risk. Large and adequate studies are needed to confirm these findings.

Peritoneal Equilibration Test Reference Values Using a 3.86% Glucose Solution During the First Year of Peritoneal Dialysis: Results of a Multicenter Study of a Large Patient Population.

BACKGROUND: The original peritoneal equilibration test (PET) was used to classify peritoneal dialysis (PD) patients using a 2.27% glucose solution. It has since been suggested that a 3.86% glucose solution be used because this provides better information about ultrafiltration (UF) capacity and the sodium (Na) sieving of the peritoneal membrane. OBJECTIVE: The aim of this study was to determine reference values for a PET using a 3.86% glucose solution (PET-3.86%). METHODS: We evaluated the PET-3.86% in a large population of incident PD patients attending 27 Italian dialysis centers. RESULTS: We evaluated the results of 758 PET-3.86% in 758 incident PD patients (1 test per patient). The mean duration of PD was 5 ± 3 months. The ratio of the concentrations of creatinine in dialysate/plasma (D/PCreat) was 0.73 ± 0.1 (median 0.74). The ratio between the concentrations of glucose at the end/beginning of the test (D/D0) was 0.25 ± 0.08 (median 0.24). Ultrafiltration uncorrected and corrected for bag overfill was respectively 776 ± 295 mL (median 781 mL) and 675 ± 308 mL (median 689 mL). Sodium sieving was 8.4 ± 3.8 mmol/L (median 8.0 mmol/L). CONCLUSION: The results of the study provide PET-3.86% reference values for the beginning of PD that can be used to classify PD patients into transport classes and monitor them over time.

Incremental peritoneal dialysis: a 10 year single-centre experience.

INTRODUCTION: Incremental dialysis consists in prescribing a dialysis dose aimed towards maintaining total solute clearance (renal + dialysis) near the targets set by guidelines. Incremental peritoneal dialysis (incrPD) is defined as one or two dwell-times per day on CAPD, whereas standard peritoneal dialysis (stPD) consists in three-four dwell-times per day. PATIENTS AND METHODS: Single-centre cohort study. Enrollement period: January 2002-December 2007; end of follow up (FU): December 2012. INCLUSION CRITERIA: incident patients with FU ≥6 months, initial residual renal function (RRF) 3-10 ml/min/1.73 sqm BSA, renal indication for PD. RESULTS: Median incrPD duration was 17 months (I-III Q: 10; 30). There were no statistically significant differences between 29 patients on incrPD and 76 on stPD regarding: clinical, demographic and anthropometric characteristics at the beginning of treatment, adequacy indices, peritonitis-free survival (peritonitis incidence: 1/135 months-patients in incrPD vs. 1/52 months-patients in stPD) and patient survival. During the first 6 months, RRF remained stable in incrPD (6.20 ± 2.02 vs. 6.08 ± 1.47 ml/min/1.73 sqm BSA; p = 0.792) whereas it decreased in stPD (4.48 ± 2.12 vs. 5.61 ± 1.49; p < 0.001). Patient survival was affected negatively by ischemic cardiopathy (HR: 4.269; p < 0.001), peripheral and cerebral vascular disease (H2.842; p = 0.006) and cirrhosis (2.982; p = 0.032) and positively by urine output (0.392; p = 0.034). Hospitalization rates were significantly lower in incrPD (p = 0.021). Eight of 29 incrPD patients were transplanted before reaching full dose treatment. CONCLUSIONS: IncrPD is a safe modality to start PD; compared to stPD, it shows similar survival rates, significantly less hospitalization, a trend towards lower peritonitis incidence and slower reduction of renal function.

Encapsulating peritoneal sclerosis in an Italian center: thirty year experience.

BACKGROUND: Encapsulating peritoneal sclerosis (EPS) is a rare but life-threatening complication of peritoneal dialysis (PD). Its incidence and prevalence are still not clearly defined. No data exist on the prevalence of EPS in Italy. OBJECTIVES: To evaluate the incidence and prevalence of EPS, and identify potential factors useful for prevention or early diagnosis of EPS. METHODS: A retrospective study in patients starting PD between 1979 and 2013 in one Italian center. Data on demographics, occurrence of EPS, time on PD, peritoneal equilibration test, and therapy for EPS were gathered. RESULTS: EPS occurred in 26/920 patients with a prevalence of 2.8 % and incidence of 1/105 patient-years. The prevalence increased with the time spent on PD: 0.4 % for PD duration <2 years, 3 % (2-4 years), 4 % (4-6 years), 6 % (6-8 years), 8 % (8-10 years), 18 % (10-12 years), 75 % (12-14 years), 67 % (>14 years). EPS prevalence was not higher in PD patients transplanted: 5/172 (2.9 %); only two of them (1.2 %) were diagnosed while with a functioning graft. In only one patient (0.6 %) was the diagnosis made during hemodialysis; the other 23 were diagnosed while still on PD. Mortality due to EPS was 38.5 %, and was associated with PD duration. Therapy with steroids reduced mortality [hazard ratio 0.047 (95 % CI: 0.008-0.273); p < 0.001]. CONCLUSIONS: In our experience the prevalence of EPS is low, but increases progressively with the duration of PD. The transfer to hemodialysis or transplantation does not appear to be a key factor for EPS. Therapy with steroids significantly improves the outcome.

Association between high ultrafiltration rates and mortality in uraemic patients on regular haemodialysis. A 5-year prospective observational multicentre study.

BACKGROUND: High ultrafiltration rate on haemodialysis (HD) stresses the cardiovascular system and could have a negative effect on survival. METHODS: The effect of ultrafiltration rate (UFR; ml/h/kg BW) on mortality was prospectively evaluated in a cohort of 287 prevalent uraemic patients in regular HD from 1 January 2000 to 31 December 2005. PATIENTS: 165 men and 122 women, age 66 +/- 13 years, on regular HD for at least 6 months, median: 48 months (range 6-372 months). Mean UFR was 12.7 +/- 3.5 ml/h/kg BW, Kt/V: 1.27 +/- 0.13, body weight (BW): 62 +/- 13 kg, PCRn: 1.11 +/- 0.20 g/kg/day, duration of dialysis: median 240 min (range 180-300 min), mean arterial blood pressure (MAP) 99 +/- 9 mm/Hg. One hundred and forty nine patients (52%) died, mainly for cardiovascular reasons (69%). Multivariate Cox regression analysis was utilized to evaluate the effect on mortality of UFR, age, sex, dialytic vintage, cardiovascular disease (CVD), diabetes, dialysis modality, duration of HD, BW, interdialytic weight gain (IWG), body mass index (BMI), MAP, pulse pressure (PP), Kt/V, PCRn. RESULTS: Age (HR 1.06; CI 1.04-1.08; P < 0.0001), PCRn (HR 0.17, CI 0.07-0.43; P < 0.0001), diabetes (HR 1.81, CI 1.24-2.47; P = 0.007), CVD (HR 1.86; CI 1.32-2.62; P = 0.007) and UFR (HR 1.22; CI 1.16-1.28; P < 0.0001) were identified as factors independently correlated to survival. We estimated the discrimination potential of UFR, evaluated at baseline, in predicting death at 5 years, calculating the relative receiver operating characteristic (ROC) curves and the cut-off that minimizes the absolute difference between sensitivity and specificity. CONCLUSIONS: High UFRs are independently associated with increased mortality risk in HD patients. Better survival was observed with UFR < 12.37 ml/h/kg BW. For patients with higher UFRs, longer or more frequent dialysis sessions should be considered in order to prevent the deleterious consequences of excessive UFR.

Burnout in health care providers of dialysis service in Northern Italy--a multicentre study.

BACKGROUND: Few data are available regarding the prevalence of burnout among dialysis health care workers. Aims of the present study were to assess and compare burnout levels in a sample of nurses and physicians working in dialysis units, and to investigate their relationships with quality of life, in a cross-sectional observational study. METHODS: A total of 344 workers from 10 dialysis centres in Northern Italy completed a battery of questionnaires including the Maslach Burnout Inventory, the MOS-36 Item Short Form Health Survey [SF36: physical (PCS) and mental (MCS) component scores] and the 30-item General Health Questionnaire (GHQ30). Data on social and demographic characteristics and working conditions were also collected. General Estimating Equations models were used for the analysis. RESULTS: Overall, burnout scores were lower than the Italian normative sample, with no significant differences between physicians and nurses. However, 30% of nurses had high emotional exhaustion vs 18% of physicians (adjusted OR 2.38, P = 0.003). Emotional exhaustion was also predicted by number of worked hours and months worked in dialysis in the previous 2 years. Depersonalisation was predicted by male gender and bad relationship with coworkers. Having no children and having a permanent hospital position predicted low personal accomplishment. PCS was lower in nurses (50.0 vs 53.3, P < 0.001), while no significant difference was found for MCS and GHQ30. Lower PCS was associated with emotional exhaustion (P = 0.007) and GHQ30 > 5 with depersonalization (P = 0.032). CONCLUSIONS: Although burnout is not a general problem in dialysis health care providers, a subgroup of them may be identified, who would benefit from supportive measures to prevent this condition. Nurses appeared more burned-out in the emotional exhaustion scale than physicians.

The kind of vascular access influences the baseline inflammatory status and epoetin response in chronic hemodialysis patients.

BACKGROUND: Arteriovenous grafts (AVG) and tunneled permanent catheters (TPC) are increasingly being used in hemodialysis (HD) patients. However, their role in baseline inflammatory status has not been fully evaluated. Aim of the study was to evaluate the influence of the current kind of vascular access on the baseline inflammatory status, marked by serum C-reactive protein (CRP), and the response to epoetin therapy in a group of iron-replete HD patients, under steady clinical conditions, without evidence of acute infections and/or inflammatory diseases. METHODS: We studied 79 patients who had been on bicarbonate HD for 8-410 months and were receiving epoetin therapy. They all had adequate iron stores and stable hemoglobin (Hb) levels. Exclusion criteria were fever, signs of infection, white blood cell count (WBC) > 10 x 1,000/microl, for at least 4 weeks before study. 48 patients (group A) had arteriovenous fistula (AVF), 18 patients (group B) AVG, 13 patients (group C) TPC. CRP, Hb, transferrin saturation, serum ferritin, WBC, serum albumin, protein catabolic rate, Kt/V, and epoetin dose (U/kg body weight/week) were measured. CRP values were log-transformed to normalize the distribution. RESULTS: Log-transformed CRP values among the 3 groups were significantly different: group A 1.81 +/- 0.48; group B 2.12 +/- 0.50, and group C 3.00 +/- 0.25 (group A vs. B p < 0.003; group B vs. C p < 0.001; group A vs. C p < 0.0001). CRP and the epoetin dose were directly correlated (r = 0.519; p < 0.0001). The epoetin doses among the 3 groups were significantly different. Multiple regression analysis confirmed AVG and TPC as factors independently influencing CRP levels. CONCLUSIONS: AVG and TPC have a higher degree of chronic inflammation than AVF. The epoetin requirement is increased in TPC and AVG compared with AVF.

Effect of oral sodium bicarbonate supplementation on interdialytic weight gain, plasma sodium concentrations and predialysis blood pressure in hemodialysis patients.

BACKGROUND: Correction of metabolic acidosis in dialysis patients should be considered of paramount importance. However, consuming sodium bicarbonate tablets during the interdialytic interval to reach predialysis bicarbonate levels of 23--24 mmol/l is not widespread due to the fear of greater interdialytic weight gain and fluid overload. For this reason we investigated in a cross-sectional and in an interventional study the effect of oral sodium bicarbonate supplementation on body weight gain, plasma sodium concentrations and predialysis blood pressure in a group of stable uremic patients on regular hemodialysis (HD) treatment. STUDY DESIGN: 110 patients (67 men, 43 women), mean age 67+/-15 (range 22--89) years, on regular chronic HD treatment for 6--372 (median 48) months were studied. 70 patients were on regular oral bicarbonate supplementation for at least 4 weeks (group A), 40 patients were not on oral bicarbonate supplementation (group B). The following parameters were recorded: dry body weight (DBW), interdialytic weight gain (IWG), body mass index (BMI), plasma sodium (Na), serum pH, serum bicarbonate (sBic), K(t)/V, normalized protein catabolic rate (PCRn), predialysis systolic (SBP) and diastolic (DBP) blood pressure, and bicarbonate therapy (g/day). 18 patients not on oral bicarbonate supplementation with sBic levels

Epoetin requirement does not depend on dialysis dose when Kt/N > 1.33 in patients on regular dialysis treatment with cellulosic membranes and adequate iron stores.

BACKGROUND: An inverse correlation between Kt/V and epoetin requirement has recently been demonstrated in stable hemodialysis (HD) patients with adequate iron stores, dialyzed with cellulosic membranes. However, there is no evidence as to whether or not this effect continues for Kt/V even in the adequate or higher range. METHODS: We investigated the relationship between Kt/V and the weekly epoetin dose in 85 stable HD patients (age 63 +/- 16 years) treated with bicarbonate HD and unsubstituted cellulose membranes for 6-338 months (median: 70 months). INCLUSION CRITERIA: HD for at least 6 months, subcutaneous rHuEPO for at least 4 months, transferrin saturation (TSAT) > or = 20%, serum ferritin > or = 100 ng/mL, hemoglobin (Hb) level targeted to approximately equal to 12 g/dL for at least 3 months. EXCLUSION CRITERIA: HBsAg and HIV positivity; need for blood transfusions or evidence of blood loss in the 3 months before the study, acute and chronic infections. To evaluate the effect of dialysis adequacy on the epoetin requirement, we also performed the same analysis after dividing of the patients according to Kt/V. Hematocrit (Hct) and Hb levels were evaluated weekly for 3 weeks; TSAT, serum ferritin, Kt/V, PCRn, serum albumin (sAlb), and weekly epoetin dose were evaluated at the end of observation. No change in dialysis or therapy prescription was made during the study. RESULTS: The results for all the patients were: Hct 36 +/- 2 %, Hb 12 +/- 0.7 g/dL, TSAT 28 +/- 7%, serum ferritin 234 +/- 171 ng/mL, sAlb 4.2 +/- 0.4 g/dL, Kt/V 1.33 +/- 0.17, PCRn 1.15 +/- 0.28 g/Kg/day, weekly epoetin dose 117 +/- 74 U/Kg. There was no correlation between Hb and Kt/V, whereas there was an inverse correlation between the reciprocal of the weekly epoetin dose and Kt/V (r = -0.448, p = 0.0001). Further regression line analysis showed a break-point for Kt/V at the level of 1.33. In the 52 patients with Kt/V < 1.33, the correlation was confirmed between epoetin and Kt/V (r = - 0.563, p = 0.0001), while in the 33 patients with Kt/V > or = 1.33, there was no correlation between epoetin dose and Kt/V (r = 0.021, p = NS). In these patients, multiple regression analysis, with the weekly epoetin dose as a dependent variable, confirmed Kt/V as a non-significant factor. CONCLUSIONS: In iron-replete HD patients on cellulosic membranes and stabilized epoetin therapy, inadequate dialysis was associated with higher epoetin requirement, but for Kt/V values > or = 1.33, there was no further effect on epoetin responsiveness.