Insight into the long-term impact of birth weight on intestinal development, microbial settlement, and the metabolism of weaned piglets.

Infant mortality of low birth body weight (LBBW) piglets can reach 10% and is mainly due to gut and immune system immaturity which can lead to a higher risk in the long term. This study aimed to assess the impact of birth body weight (BBW) on piglet metabolism, gut status, and microbial profile from weaning to 21 d postweaning. At birth, 32 piglets were selected for their BBW and inserted into the normal BBW (NBBW:1.38 ±â€…0.09 g) or the LBBW (0.92 ±â€…0.07 g) group. The piglets were weighed weekly from weaning (d0) to d21. At d9 and d21, 8 piglets/group were slaughtered to obtain the distal jejunum for morphology, immunohistochemistry, and gene expression analysis, colon content for microbiota and short-chain fatty acid (SCFA) analysis, and intestinal content for pH measurement. Blood was collected for metabolomic, haptoglobin (Hp), and reactive oxygen metabolite (ROM) analysis. The LBBW group had a lower body weight (BW) throughout the study (P < 0.01), a lower average daily gain from d9-d21 (P = 0.002), and lower feed intake (P = 0.02). The LBBW piglets had lower Hp at d9 (P = 0.03), higher ROMs at d21 (P = 0.06), and a net alteration of the amino acid (AA) metabolism at d9 and d21. A higher expression of NFKB2 was observed in the LBBW piglets at d9 (P = 0.003) and d21 (P < 0.001). MYD88 expression was enhanced in NBBW piglets at d9 (P < 0.001). The LBBW piglets had a lower villus height, absorptive mucosal surface (P = 0.01), and villus height:crypt depth ratio (P = 0.02), and a greater number of T-lymphocytes in both the epithelium and the crypts (P < 0.001) at d21. At d21, the LBBW piglets had higher lactic acid, acetate, butyrate, and valerate, and also higher SCFA in the colon (P < 0.05). The LBBW piglets had a higher Shannon index (P = 0.01) at d9 and a higher abundance of SCFA-fermenting bacteria. In conclusion, the present study confirmed that LBBW could impact the gut mucosal structure, immunity, and inflammatory and oxidative status, leading to an altered AA metabolism, and delaying the recovery from weaning.

The drawback of the high prolificacy selection in the swine industry in the past decades is an increase in the number of piglets born with a low birth body weight (LBBW). This study aimed to assess performance, metabolism, gut status, and microbial profile in piglets born with low (0.92 ±â€…0.07 g) and normal birth body weight (1.38 ±â€…0.09 g). Piglets were weighed weekly from weaning (25 d) until 3 weeks postweaning (end of the trial). At d9 and d21, 8 piglets/group were slaughtered to obtain blood for metabolomic, haptoglobin, reactive oxygen metabolite analyses, colon content for microbiota and short-chain fatty acid, intestinal content for pH measurement, distal jejunum for morphology, immunohistochemistry, and gene expression. The LBBW resulted in lower body weight through the study (P < 0.001), lower average daily gain from d9 to d21 (P = 0.002), and lower feed intake (P = 0.02). The LBBW piglets had a lower villus height, absorptive mucosal surface (P = 0.01), and villus height:crypt depth ratio (P = 0.02), and a greater number of T-lymphocytes in both the epithelium and the crypts (P < 0.001) at d21. In conclusion, the present study confirmed that LBBW could impact the gut mucosal structure, immunity, and inflammatory and oxidative status, leading to an altered AA metabolism, and delaying the recovery from weaning.

Linseed supplementation in the diet of fattening pigs: Effect on the fatty acid profile of different pork cuts.

Linseed supplementation improves the fatty acid (FA) profile of meat, primarily by increasing α-linolenic acid (ALA). Pork is one of the most consumed meats, though the high level of saturated FA, therefore, a change of the FA profile is needed to improve the health properties. The aim of this work was to study the influence of extruded linseed supplementation on the FA profile in 5 different pork cuts, increasing their nutraceutical properties. Sixty pigs were divided into two groups, which were fed two different diets: control (C) and experimental (L, 8% supplementation with extruded flaxseed). Five cuts were sampled: backfat (Bf), bacon (B), Boston shoulder (Bs), ham lean part (Hl) and ham fatty part (Hf). The L diet reduced fat content in Hf (-6%) and B (-11%), while the other cuts did not show differences. Moreover, L group showed a higher level of n-3 PUFA (approx. 9-fold), with a significant reduction in the n-6/n-3 from 20 to 2.5. In cuts rich in fat (Bf, B and Hf) of L group, the level of n-3 PUFA was higher than the thresholds set by EU to obtain the claim "Source of omega-3 fatty acids". In contrast, the lean cuts (Hl and Bs) did not exceed the threshold of n-3 PUFA required to obtain the claim, as consequence of the low level of fat. The results demonstrated that a diet with 8% extruded linseed enhanced the nutraceutical quality of pork meat.

Effect of Cooking with Superheated (SHS) vs. Standard Steam Oven on the Fatty Acids Profile of Different Kinds of Meat and Fish.

We compared the effect of two different kinds of steam oven-a standard (SO) and a superheated steam (SHS) oven-on four different kinds of samples: hamburgers, bovine steaks, pork steaks, and salmon fillets. Ten samples of each meat/fish were divided into three parts. Then samples were analyzed as (i) raw, (ii) cooked with SO, and (iii) cooked with SHS. For each sample, we determined the proximate composition, fatty acid composition and thiobarbituric acid reactive substances (TBARS). The results of fatty acid composition were processed both with a linear model and with a multivariate approach by using three complementary discriminant analysis techniques: canonical (CAN), stepwise (St) and discriminant (DA). SHS was effective in degreasing hamburgers but not the other kinds of samples. Cooking methods selectively affected the fatty acid profile of samples, SHS being higher in MUFA and lower in PUFA n-3 than SO. This result was also confirmed by the discriminant analysis. Finally, samples cooked with SHS showed a lower fatty acid oxidation extent than SO, as the TBARS value was significantly lower in the SHS than in the SO, irrespective of the type of meat/fish cooked.

Supplementation of Enriched Polyunsaturated Fatty Acids and CLA Cheese on High Fat Diet: Effects on Lipid Metabolism and Fat Profile.

Epidemiological studies have demonstrated a positive relationship between dietary fat intake and the onset of several metabolic diseases. This association is particularly evident in a diet rich in saturated fatty acids, typical of animal foods, such as dairy products. However, these foods are the main source of fatty acids with a proven nutraceutical effect, such as the ω-3 fatty acid α-linolenic acid (ALA) and the conjugated linoleic acid (CLA), which have demonstrated important roles in the prevention of various diseases. In the present study, the effect of a supplementation with cheese enriched with ω-3 fatty acids and CLA on the metabolism and lipid profiles of C57bl/6 mice was evaluated. In particular, the analyses were conducted on different tissues, such as liver, muscle, adipose tissue and brain, known for their susceptibility to the effects of dietary fats. Supplementing cheese enriched in CLA and ω-3 fats reduced the level of saturated fat and increased the content of CLA and ALA in all tissues considered, except for the brain. Furthermore, the consumption of this cheese resulted in a tissue-specific response in the expression levels of genes involved in lipid and mitochondrial metabolism. As regards genes involved in the inflammatory response, the consumption of enriched cheese resulted in a reduction in the expression of inflammatory genes in all tissues analyzed. Considering the effects that chronic inflammation associated with a high-calorie and high-fat diet (meta-inflammation) or aging (inflammaging) has on the onset of chronic degenerative diseases, these data could be of great interest as they indicate the feasibility of modulating inflammation (thus avoiding/delaying these pathologies) with a nutritional and non-pharmacological intervention.

Current Management of Hyperkalemia in Non-Dialysis CKD: Longitudinal Study of Patients Receiving Stable Nephrology Care.

BACKGROUND: No study has explored the limitations of current long-term management of hyperkalemia (HK) in outpatient CKD clinics. METHODS: We evaluated the association between current therapeutic options and control of serum K (sK) during 12-month follow up in ND-CKD patients stratified in four groups by HK (sK ≥ 5.0 mEq/L) at baseline and month 12: Absent (no-no), Resolving (yes-no), New Onset (no-yes), Persistent (yes-yes). RESULTS: We studied 562 patients (age 66.2 ± 14.5 y; 61% males; eGFR 39.8 ± 21.8 mL/min/1.73 m2, RAASI 76.2%). HK was "absent" in 50.7%, "resolving" in 15.6%, "new onset" in 16.6%, and "persistent" in 17.1%. Twenty-four hour urinary measurements testified adherence to nutritional recommendations in the four groups at either visit. We detected increased prescription from baseline to month 12 of bicarbonate supplements (from 5.0 to 14.1%, p < 0.0001), K-binders (from 2.0 to 7.7%, p < 0.0001), and non-K sparing diuretics (from 34.3 to 41.5%, p < 0.001); these changes were consistent across groups. Similar results were obtained when using higher sK level (≥5.5 mEq/L) to stratify patients. Mixed-effects regression analysis showed that higher sK over time was associated with eGFR < 60, diabetes, lower serum bicarbonate, lower use of non-K sparing diuretics, bicarbonate supplementation, and K-binder use. Treatment-by-time interaction showed that sK decreased in HK patients given bicarbonate (p = 0.003) and K-binders (p = 0.005). CONCLUSIONS: This observational study discloses that one-third of ND-CKD patients under nephrology care remain with or develop HK during a 12-month period despite low K intake and increased use of sK-lowering drugs.

Drying Techniques and Storage: Do They Affect the Nutritional Value of Bee-Collected Pollen?

In this study, the effect of different drying processes (freeze-drying (FD), microwave-assisted drying (MWD) and classic hot air drying (HAD)) on the polyphenols, flavonoids, and amino acids content was investigated on bee-collected chestnut, willow and ivy pollen for human consumption. Furthermore, the pollen chemical properties were monitored after three and six months of storage, and then analyzed using a multivariate approach. Chestnut pollen was the richest source of polyphenols, flavonoids, and rutin, while ivy pollen contained the highest amount of total and free amino acids, and total and free proline. Drying and storage affected pollen chemical composition with species-dependent effects. MWD allowed the best retention of flavonoids in chestnut pollen for up to six months of storage. All drying techniques led to a depletion of flavonoids in willow pollen; however, MWD ensured the highest flavonoids content after six months. FD and MWD did not lead to flavonoids depletion in ivy pollen during storage. Additionally, storage did not affect the rutin content, which was highest in FD willow samples after six months. Notably, both FD and MWD techniques are efficient in preserving amino acids-related quality of bee pollen up to six months of storage.

[Remote patient monitoring in dialysis patients: the "change of pace" for home dialysis.] / Monitoraggio da remoto del paziente in dialisi: il cambio di passo per la dialisi domiciliare?

Lockdown and self-isolation are to date the only solution to limit the spread of recent outbreak of coronavirus disease (CoViD-19), highlighting the great advantage of home dialysis in a patient otherwise forced to travel from / to the dialysis center to receive this "life-saving" treatment. Indeed, to prevent spreading of CoViD-19 infection among extremely fragile dialysis patients, as well as among dialysis workers, hemodialysis (HD) centers are adopting specific procedures ("dedicated" dialysis facilities, portable osmosis, etc.) with a great economic and organizational commitment. Peritoneal dialysis (PD) represents a type of home dialysis therapy not yet adequately implemented to date, in spite of safe and simple practice, as well as similar dialytic efficiency vs in-center hemodialysis. Remote patient monitoring (RPM) systems have been developed in automated PD (APD) cyclers in order to improve the acceptance of this dialysis method, to increase the compliance to the prescribed therapy and to control treatment adequacy. In this review we assess the potential advantages of RPM in APD, that are the chance for patients to acquire greater independence and safety in the home treatment, to allow better access to care for residents in remote areas, faster resolution of problems, reduction in hospitalizations and mortality rates, as well as time and cost saving for both the patient and the staff. The use of medical devices (sphygmomanometer, glucometer, balance, etc.), connected by wireless to the clinician's portal, might also allow a wider diffusion of incremental dialysis, an integrated therapy that combines conservative management of ESKD patients with a soft dialysis based on the residual kidney function and symptomatology, with potential prognosis and economic benefits. Although the majority of the studies are small and observational, a wider use of RPM systems is desirable to broaden the spread of home dialysis, as we learnt from Coronavirus pandemic.

Evaluation of Chemical Composition of Two Linseed Varieties as Sources of Health-Beneficial Substances.

Linseed (Linum usitatissimum L.) is becoming more and more important in the health food market as a functional food, since its seeds and oil represent a rich source of bioactive compounds. Its chemical composition is strongly correlated with, and dependent on, genetic characteristics. The aim of this study was to evaluate the variation in seed yield, oil content, fatty acid composition and secondary metabolite profiles between a low-linolenic linseed variety, belonging to the Solin-type group (Solal), and a high-linolenic traditional one (Bethune), cultivated, both as spring crops, in open field conditions of Central Italy. The achieved results pointed out the different behavior of the two varieties in terms of growth cycle, oil content, and some important yield components, such as capsule number per plant and thousand seed weight. There were also significant differences in seed composition regarding total phenols, total flavonoids, antioxidant activities as well as in carotenoid, tocopherol, and tocotrienol profiles between the two varieties. In particular, Solal was characterized by the greatest contents of oil, phenols, flavonoids, α- and δ- tocotrienol, together with the highest antioxidant activity. Bethune, on the contrary, showed the highest amounts of carotenoids (lutein and ß-carotene). These results indicate a clear effect of the genetic characteristics on the biosynthesis of these secondary metabolites and, consequently, on the related antioxidant activity. Our findings suggest that the mutation process, responsible for the selection of the low-linolenic cultivar, is able to modify the biosynthetic pathways of carotenoids and phenolics.

Ancient apple cultivars from Garfagnana (Tuscany, Italy): A potential source for 'nutrafruit' production.

Ancient apple cultivars are known for their organoleptic properties over a small geographic area, but little is known of their nutraceutical properties, which might be useful in large-scale breeding programmes. Nine ancient apple cultivars from Tuscany (Italy) were characterized for their organoleptic properties, phenolic profiles, and antioxidant activity. These cultivars had high polyphenol concentrations (principally flavanols and phenolic acids) and high total antioxidant capacity compared with most commercial apple cultivars. Fruits from the cultivars 'San Michele' and 'Del Debbio' showed a good compromise between fruit size and solid soluble content, and might be suitable for fresh consumption, while fruit from 'Benito', 'Della Piastra', 'Lugliese Grisanti', 'Del Sangue' and 'Ruggine' had high polyphenol contents and excellent antioxidant capacity, and may be suitable for breeding programmes. 'Ruggine' fruit could also be used for sweet juices with good nutraceutical properties due to their high soluble solid content and high flavanol concentration.

[Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program].

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Effect of different types of olive oil pomace dietary supplementation on the rumen microbial community profile in Comisana ewes.

Olive oil pomace (OOP) is a bio-waste rich in highly soluble polyphenols. OOP has been proposed as an additive in ruminant feeding to modulate rumen fermentations. Three groups of ewes were fed the following different diets: a control diet and two diets supplemented with OOP, obtained with a two-phase (OOP2) or three-phase (OOP3) olive milling process. Rumen liquor (RL) showed a higher content of 18:3 cis9 cis12 cis15 (α-linolenic acid, α-LNA) with OOP2 inclusion, and of 18:2 cis9 trans11 (rumenic acid, RA) with OOP3 inclusion. The overall composition of the RL microbiota did not differ among treatments. Significant differences, between control and treated groups, were found for six bacterial taxa. In particular, RL microbiota from animals fed OOPs showed a reduction in Anaerovibrio, a lipase-producing bacterium. The decrease in the Anaerovibrio genus may lead to a reduction in lipolysis, thus lowering the amount of polyunsaturated fatty acids available for biohydrogenation. Milk from animals fed OOP showed a higher content of 18:1 cis9 (oleic acid, OA) but the α-LNA concentration was increased in milk from animals treated with OOP2 only. Therefore, inclusion of OOP in ruminant diets may be a tool to ameliorate the nutritional characteristics of milk.

Nutritional treatment of advanced CKD: twenty consensus statements.

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Effect of increasing amounts of olive crude phenolic concentrate in the diet of dairy ewes on rumen liquor and milk fatty acid composition.

Agro-industrial by-products contain several secondary plant metabolites, such as polyphenols, tannins, saponins, and essential oils. The effects of these compounds on animal metabolism may vary significantly according to the dose, the chemical nature of the molecules, and the overall composition of the diet. In the Mediterranean area, the olive oil extraction is associated with 2 by-products: olive pomace and wastewater, both rich in polyphenols. In particular, wastewater may be further processed to obtain olive crude phenolic concentrate (OCPC). An experiment was carried out aiming to evaluate animal performance, milk fatty acid (FA) profile, diversity of rumen microbial population, and rumen liquor FA profile in dairy ewes fed diets containing extruded linseed (EL) and increasing doses of OCPC. Twenty-eight Comisana ewes in mid lactation were allotted to 4 experimental groups. The experiment lasted 5 wk after 3 wk of adaptation. Diets were characterized by lucerne hay administrated ad libitum and by 800 g/ewe and day of 4 experimental concentrates containing 22% of EL on dry matter and increasing dose of OCPC: 0 (L0), 0.6 (L0.6), 0.8 (L0.8), and 1.2 (L1.2) g of OCPC/kg of dry matter. Milk yield was daily recorded and milk composition was analyzed weekly. At the beginning and at the end of the experiment, samples of rumen liquor were collected to analyze FA profile, changes in rumen microbial population, and dimethylacetal (DMA) composition. The inclusion of OCPC did not affect milk yield and gross composition, whereas milk from L0.8 and L1.2 sheep contained higher concentrations of linoleic (+18%) and α-linolenic acid (+24%) and lower concentration of the rumen biohydrogenation intermediates. A similar pattern was observed for rumen liquor FA composition. No differences were found in the diversity of the rumen microbial population. Total amount of DMA did not differ among treatments, whereas significant differences were found in the concentration of individual DMA; in the diet with a higher amount of OCPC, DMA 13:0, 14:0, 15:0, and 18:0 increased, whereas DMA 16:0 decreased. Probably the presence of polyphenols in the diet induced a rearrangement of bacteria membrane phospholipids as a response to the rumen environment stimulus. Overall, the use of OCPC allowed a significant increase in the polyunsaturated FA content of milk, probably due to a perturbation of the rumen biohydrogenation process. Further studies are needed to understand the correlation between diet composition and the pattern of DMA in rumen liquor.

Controversial issues in CKD clinical practice: position statement of the CKD-treatment working group of the Italian Society of Nephrology.

This position paper of the study group "Conservative treatment of Chronic Kidney Disease-CKD" of the Italian Society of Nephrology addresses major practical, unresolved, issues related to the conservative treatment of chronic renal disease. Specifically, controversial topics from everyday clinical nephrology practice which cannot find a clear, definitive answer in the current literature or in nephrology guidelines are discussed. The paper reports the point of view of the study group. Concise and practical advice is given on several common issues: renal biopsy in diabetes; dual blockade of the renin-angiotensin-aldosterone system (RAAS); management of iron deficiency; low protein diet; dietary salt intake; bicarbonate supplementation; treatment of obesity; the choice of conservative therapy vs. dialysis. For each topic synthetic statements, guideline-style, are reported.

Management of CKD-MBD in non-dialysis patients under regular nephrology care: a prospective multicenter study.

BACKGROUND: Knowledge about mineral bone disorder (MBD) management in non-dialysis chronic kidney disease (ND-CKD) patients is scarce, although essential to identifying areas for therapeutic improvement. METHODS: We prospectively evaluated current management of CKD-MBD in two visits, performed 6 months apart, in 727 prevalent ND-CKD stage 3b-5 patients from 19 nephrology clinics. Therapeutic inertia was defined as lack of treatment despite hyperphosphatemia and/or hypocalcemia, and/or hyperparathyroidism. The primary endpoint was the prevalence of achieved target for CKD-MBD parameters and related treatments (phosphate binders, vitamin D and calcium supplements). The secondary endpoint was the assessment of prevalence and clinical correlates of therapeutic inertia. RESULTS: Over 65 % of patients did not reach parathormone (PTH) targets, while 15 and 19 % did not reach phosphate and calcium targets, respectively. The proportion of untreated patients decreased from stage 3b to 5 (at baseline, from 60 to 16 %, respectively). From baseline to the 6-month visit, the achievement of targets remained stable. Low protein diet was prescribed in 26 % of patients, phosphate binders in 17.3 % (calcium-based binders 15.5 %, aluminium binders 1.8 %), and vitamin D in 50.5 %. The overall prevalence of therapeutic inertia at the 6-month visit was 34.0 % (for hyperphosphatemia, 54.3 %). Compared to CKD stage 3, the likelihood of therapeutic inertia was 40 and 68 % lower at stage 4 and 5, respectively. CONCLUSIONS: PTH, calcium and phosphate targets were not reached in a significant proportion of patients. One-third of patients with at least one MBD parameter not-at-target remained untreated. Therapeutic inertia regarding CKD-MBD treatment may be a major barrier to optimizing the prevention and cure of CKD-MBD.

[Clinical experience with ferric carboxymaltose in non-dialysis chronic kidney disease]. / Ferro carbossimaltosio nella malattia renale cronica non dialitica: una iniziale esperienza clinica.

BACKGROUND: Patients with non-dialysis-dependent chronic kidney disease (ND-CKD) often show anemia and iron deficiency despite oral iron supplementation caused by poor iron absorption, intolerance and non-compliance. METHODS: We prospectively followed seven adult patients with ND-CKD (eGFR <60 ml/min/1.73m2), anemia (Hb<11 g/dl or treatment with ESA), iron deficiency (TSAT<20% and/or ferritin<100 ng/mL) and intolerant or non-responders to oral iron supplementation. Patients received ferric carboxymaltose (FCM) (single dose of 500 mg iv) eventually followed by further doses if iron deficiency persisted. Hemoglobin, ferritin, TSAT and ESA doses were recorded at baseline and after 2, 4, 8, 12, 16, 20 and 24 weeks. RESULTS: After 2 weeks of FCM, ferritin increased from 5348 to 222154 ng/mL (P<0.05) and remained steady thereafter. The increase of TSAT from baseline (115%) was more gradual being significant from week 4 (198%) up to week 24 (2412%). During the study, patients received on average 2.31.0 injections of FCM, to the amount of 1143440 mg. Hb levels remained stable throughout the study, despite a significant reduction of ESA dosage (from 3426 g/week at baseline to 1116 and 1710 g/week, after 4 and 24 weeks, respectively). On average, the ESA dose saving was 2024 g/week. Even considering the higher cost of FCM, ESA dose reduction allowed shortening overall costs by 673/patient during the 24 weeks of study. CONCLUSION: In ND-CKD patients, FCM is effective in correcting iron deficiency and associated with stable Hb levels and significant decrease of ESA dosage. This allows a marked reduction of costs for anemia correction.

Anaemia management in non-dialysis chronic kidney disease (CKD) patients: a multicentre prospective study in renal clinics.

BACKGROUND: Knowledge on anaemia management in non-dialysis chronic kidney disease (ND-CKD) patients regularly followed in renal clinics is scarce although being essential to identifying areas of therapeutic improvement. METHODS: We prospectively evaluated anaemia management in two visits, performed 6 months apart, in 755 prevalent ND-CKD stage 3b-5 patients followed in 19 nephrology clinics from ≥6 months. Anaemia was defined as severe (Hb <11 g/dL) or mild (Hb: 11-13.5 in males and 11-12 g/dL in females); iron deficiency (ID) was defined as transferrin saturation (TSAT) <20% and/or ferritin <100 ng/mL. Primary endpoint was the change of anaemia and ID prevalence between baseline and 6-month visit. Secondary endpoint was the prevalence of clinical inertia to either ESA or iron supplementation, that is, the lack of ESA or iron prescription despite Hb <11 g/dL or ID. RESULTS: Age was 69 ± 13 years and GFR 27.5 ± 10.0 mL/min/1.73 m(2); male gender, diabetes and prior cardiovascular disease were 57.2, 30.1 and 30.1%, respectively. Prevalence of severe and mild anaemia was 18.0 and 44.0% at baseline and remained unchanged at Month 6 (19.3 and 43.2%). ID was prevalent at both visits (60.1 and 60.9%). Clinical inertia to ESA was similar at baseline and at Month 6 (39.6 and 34.2%, respectively, P = 0.487) and it was less frequent than clinical inertia to iron therapy (75.7 and 72.0%, respectively). CONCLUSIONS: This study shows that anaemia prevalence is unexpectedly high in the setting of tertiary nephrology care. This was due to a persistent clinical inertia in the anaemia management, remarkable for iron supplementation and less critical, but still significant, for ESA treatment.

[Amino acid loss during dialysis treatment]. / Perdita di aminoacidi nel corso di terapia emodialitica extracorporea.

Protein-calorie malnutrition is a widespread complication in hemodialysis (HD) patients and is associated with increased mortality. The pathogenesis of malnutrition is multifactorial. Intradialytic amino acid (AA) loss is considered one of the cofactors in the complex mechanisms that lead to malnutrition in HD patients. It has been documented that in each dialysis session there is a 6-8 gram loss of AA into the dialysate, which worsens with the use of high-flux membranes. The intradialytic AA loss is variably compensated by reduction of liver synthesis and increased AA release from muscle stores. In malnourished HD patients the serum AA concentration, especially branched-chain AA (BCAA), is correlated with nutritional status and anorexia, whereas BCAA supplementation improves the nutritional parameters and increases appetite. Further studies are necessary to clarify the role of alterations of AA metabolism in the pathogenesis of malnutrition and the potential beneficial effects of BCAA supplementation or alternative treatments in malnourished patients.

[Role of paracalcitol in the management of non-dialysis CKD: state of art and... Unmet needs]. / Ruolo del paracalcitolo nella terapia conservativa della malattia renale cronica: stato dell'arte e... Unmet needs.

Chronic kidney disease (CKD) is associated with a high risk of cardiovascular morbidity and mortality due to the high prevalence of traditional risk factors and the presence of factors specific to CKD. Vitamin D deficiency and secondary hyperparathyroidism are the earliest complications in CKD, and observational data show that low plasma vitamin D is an independent predictor of death in patients with CKD. Oral supplementation with active oral vitamin D appears to be associated with greater survival but a significant improvement in renal outcome has not been demonstrated, probably because of its unwanted side effects (increase in plasma calcium and phosphate levels). Oral paracalcitol, a new vitamin D receptor activator, is now available for CKD patients not yet on dialysis. It suppresses PTH with a low incidence of increased serum calcium and phosphate levels in patients treated with dialysis and when high doses are administered. Furthermore, recent data show that paracalcitol treatment in CKD patients also results in a significant reduction of albuminuria, which is a major risk factor for cardiorenal outcome. The antiproteinuric effect of paracalcitol appears to be the result of intrarenal suppression of the renin-angiotensin system (RAS). Therefore, paracalcitol may be mostly effective in reducing albuminuria in patients already treated with RAS inhibitors who show compensatory increments of RAS components. Studies in large patients series and with adequate follow-up are needed to evaluate the effects of long-term paracalcitol treatment in CKD and its potential role in improving renal outcome in comparison not only with placebo but also other vitamin D metabolites and analogues.

Stability of target hemoglobin levels during the first year of epoetin treatment in patients with chronic kidney disease.

BACKGROUND AND OBJECTIVES: Instability of hemoglobin levels during epoetin therapy is a new problem in hemodialysis. We evaluated extent and correlates of time in target, that is, the time spent with hemoglobin > or = 11 g/dl during the first year of epoetin and its association with renal survival. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were collected in 917 visits for 12.0 mo in 119 patients with chronic kidney disease; thereafter, patients started renal survival analysis for 10.1 mo. At baseline, hemoglobin was 10.0 +/- 0.8 g/dl and GFR was 22.1 +/- 14.2 ml/min per 1.73 m2. RESULTS: Hemoglobin target, reached in 1.5 mo, was steadily maintained in only 24% of patients. Time in target was not merely due to differences in time to target; after first achievement of target, in fact, a reduction of hemoglobin < 11 g/dl occurred in 51% of patients. At multivariate analysis, male gender, basal GFR and hemoglobin levels, first epoetin dose, and iron supplementation were directly associated with length of time in target. A lower risk for renal death (dialysis n = 53; death n = 8) was detected in the higher tertile of time in target (11.3 mo) versus lower tertile (3.2 mo). This difference persisted at Cox analysis after adjustment for age, gender, GFR, BP, and proteinuria. CONCLUSIONS: In chronic kidney disease, time in target during the first year of epoetin therapy is frequently short depending not only on time to target but also on post-target hemoglobin reductions, correlates with male gender, timing, and intensity of initial therapy and is coupled with better renal survival.