Diabetics on dialysis in Italy: a nationwide epidemiological study.

BACKGROUND: Diabetes mellitus is a common disease, comprising 4-8% of the general population and up to 45% of new dialysis patients in industrialized countries. METHODS: We performed a nationwide study with the aim of analysing the approach of various centres to diabetic patients and to gather data on the epidemiology, clinical characteristics and complications of type 1 and type 2 diabetics. RESULTS: We acquired the data from 513 dialysis centres, 3665 prevalent diabetic patients and 4337 diabetic patients who started dialysis in the previous 10 years. Patient education and dialysis initiation: Sixty percent of the centres educate the patient regarding diet, pharmacological therapy and prevention of diabetic complications; in 245 centres (48%), this task belonged exclusively to the nephrologist and not to a multidisciplinary team. Seventy percent of the centres reported planning the initiation of dialysis and preparing the fistula between 1 and 3 months (78.5%) before the initiation of dialysis. Epidemiological and clinical data: Diabetic patients (56.9% males) represented 12.5% of the total dialysis population in Italy. The ratio between diabetes type 2 and type 1 was 5.3. The initial treatment was haemodialysis (HD) in 2533 patients (bicarbonate HD 88.8%) and peritoneal dialysis (PD) in 405 patients (CAPD 82.2%). During their dialytic life, 383 patients (226 from HD and 157 from PD) changed treatment modality, mainly because of cardiocirculatory instability (158 cases) or infection of the catheter tunnel/peritoneum (89 cases). The changes were mainly directed from bicarbonate HD and CAPD towards diffusive-convective extracorporeal techniques. Blood glucose (mean 154 +/- 56.8 mg/dl) exceeded 200 mg/dl in 15.2% of patients; serum cholesterol was >200 mg/dl in 39.3% of patients; serum triglycerides exceeded 200 mg/dl in 39.2% of patients and mean values for glycosylated haemoglobin was 7.2 +/- 1.8%. The nutritional state was judged to be normal in 59.6% of patients, 16.2% appeared to be mildly malnourished and 3% severely malnourished; 21.1% of subjects were obese. Echocardiography showed left ventricular hypertrophy in 90% of patients and echocolordoppler examination of the great vessels showed pathological findings (plaques and stenoses) in 73%. Pharmacological therapy. Sixty-nine percent of patients were treated with antihypertensive drugs, mainly calcium antagonists (50%) and ACE inhibitors (27%). Nitrates were prescribed for 33% of patients; antiplatelet or anticoagulant drugs were prescribed for 37% of patients. CONCLUSIONS: The present study demonstrates that the prevalence of diabetics in dialysis continues to increase in Italy, but remains less than that in Northern European countries. Type 2 diabetes is as dangerous as type 1 in terms of serious complications. There appears to be a greater awareness on the part of nephrologists of the serious problems associated with the care of diabetic patients in dialysis. The ideal dialytic modality has not been determined, dialysis is often not initiated in a timely manner and optimal drug therapy is not always prescribed. The aspirations to treat the diabetic dialysis patient according to currently accepted best practice guidelines still need to be fully realized.

Blood volume controlled hemodialysis in hypotension-prone patients: a randomized, multicenter controlled trial.

BACKGROUND: Recently we have devised and tested a biofeedback system for controlling blood volume (BV) changes during hemodialysis (HD) along an ideal trajectory (blood volume tracking, BVT), continuously modifying the weight loss rate and dialysate conductivity. This multicenter, prospective, randomized, crossover study aimed to clarify whether BVT (treatment B) can improve hypotension-prone patients' treatment tolerance, compared with conventional hemodialysis (treatment A). METHODS: Thirty-six hypotension-prone patients enrolled from 10 hemodialysis (HD) centers were randomly assigned to either of the study sequences ABAB or BABA, each lasting four months. RESULTS: A 30% reduction in intradialytic hypotension (IDH) events was observed in treatment B as compared with A (23.5% vs. 33.5%, P = 0.004). The reduction was related to the number of IDH in treatment A (y = 0.54x + 5; r = 0.4; P < 0.001): the more IDH episodes in treatment A, the better the response in treatment B. The best responders to treatment B showed pre-dialysis systolic blood pressure values higher than the poor responders (P = 0.04). A 10% overall reduction in inter-dialysis symptoms was obtained also in treatment B compared to A (P < 0.001). Body weight gain, pre-dialysis blood pressure, intradialytic weight loss as well as Kt/V did not differ between the two treatments. CONCLUSIONS: An overall improvement in the treatment tolerance was observed with BVT, particularly intradialytic cardiovascular stability. Patients with the highest incidence of IDH during conventional HD and free from chronic pre-dialysis hypotension seem to respond better. Inter-dialysis symptoms also seem to improve with control of BV.