[2004 census of the Italian nephrology and dialysis units]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani.

The Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyze structural and human resources, organizational aspects, activities and epidemiological data. An online 158-item questionnaire for the year 2004 was used. Three hundred sixty-three public renal units, 303 satellite dialysis centers and 295 private dialysis centers were identified, resulting in a total of 961 dialysis centers (16.4 per million population, pmp). The inpatient renal beds were 2,742 (47 pmp). Renal and dialysis activity was performed by 3,728 physicians (64 pmp), of whom 2,964 (80%) were nephrologists. There was no permanent medical assistance in 41% of the satellite dialysis centers. Renal admissions (1,800 pmp) and renal biopsies (99 pmp) were done. The management of the acute renal failure was one of the most relevant activities in the public renal units (13,456 cases, 230 pmp). In 2004 9,858 new cases of end-stage renal disease (169 pmp) were diagnosed. On December 31st 2004, 43,293 patients (741 pmp) were on renal replacement therapy, of whom 89.7% on hemodialysis and 10.3% on peritoneal dialysis. Renal transplant recipients were 16,765 (287 pmp). The benchmark data derived from this census show interesting comparisons between centers, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

[Subjective perception of maladjustment risk factors]. / La percezione soggettiva dei fattori disadattanti al lavoro.

Maladjustment at work results from organizational and relational features of the work, the so-called fourth type factors; they include working hours, ways and contents of working activities, and horizontal and vertical business relations. The study reports the percentage of sensed disturbing factors in workers with maladjustment and disaffection at work. Data have been taken from 1382 white collars, 1117 males and 265 females, observed from January 2006 to June 2007 for Health Surveillance. Maladjustment prevalence was higher in females than in males. As individual variables, ageing and family care increased the prevalence of maladjustment among females, whilst a higher prevalence of maladjustment were found in youngest and unmarried males. A very different perception of work harmfulness were found between sexes. As risk factors, female have denounced more wear and tear and authoritarian management; male denounced physical strain.

[Census 2004 of the Italian Renal and Dialysis Units--Piemonte, Liguria and Valle d'Aosta]. / Censimento 2004 dei Centri di Nefrologia e Dialisi italiani. Piemonte--Liguria--Valle d'Aosta.

The Italian Society of Nephrology (SIN) promoted a national survey in order to obtain detailed information from all Renal and/or Dialysis Units using the on-line questionnaire (158 items) regarding structural and technological resources, medical workforce organisation and activity features. The purposes of this initiative were to obtain regional benchmarks as references for renal units and to describe the current Italian renal network in order to plan further interventions for the next 5 years. In this paper data of the first three Italian Regions (Piemonte, Liguria and Valle d'Aosta) which completed the survey (100% of the units) are reported. Main findings in the 3 Regions. A) Epidemiology: prevalence of dialysis patients = 709, 720, 787 pmp (per million population); prevalence of transplanted patients = 325, 387, 279 pmp; incidence of dialysis patients = 166, 191, 156 pmp; gross mortality of dialysis patients = 13.7, 15.0, 13.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 74, 83, 76%, central venous catheter = 18, 12, 15%, vascular graft = 8, 5, 9%. B) Structural resources: hospital's number of beds = 49, 72, 49 pmp, dialysis places = 166, 158, 164 pmp. C) Personnel resources: renal physicians = 44, 47, 41 pmp, renal nurses = 186, 194, 205 pmp; each renal physician takes care of 16, 15, 19 dialysis patients and each renal nurse cares for 3.8, 3.7, 3.8 dialysis patients. D) Activity: admission to hospital = 1507, 2392, 1606 pmp, renal biopsies = 109, 133, 57 pmp. Despite discrepancies in population density in the three Regions, most indexes are surprisingly similar and show the satisfactory level of renal care attained in the Northwestern Italian area. Further improvements in health care management can be predicted as a consequence of a direct comparison between needs and results in the various Regions of the Country.

[Standardization criteria to ensure the uniformity of data collection by the Italian Registry of Dialysis and Transplantation]. / Criteri di uniformità per la raccolta dei dati del Registro Italiano di Dialisi e Trapianto.

The Italian Registry of Dialysis and Transplantation (RIDT) collects data concerning patients in renal replacement therapy (RRT) sent from Regional Registries. Until 2003, the data were sent in summary tables. From 2004, each region has been sending patient data as single non-summarized forms (i.e. one record for each patient). This paper summarizes the collection criteria and the ideal method to codify data ensuring that data sent to the RIDT are consistent. This standardization process is necessary to ensure the statistical analyzability of the data and their comparability with data from other registries. Moreover, the standardization process is the initial step in allowing the RIDT to obtain clinical data to transform the registry from an epidemiological registry to a clinical governance instrument.

Death in conditions of cachexia: the price for the dialysis treatment of the elderly?

Death in conditions of cachexia is increasing in potential dialysis patients, as treated cohorts are aging, the mean age of new patients increased and access to treatment is unlimited. The present study analyzes the clinical features of 417 deaths in conditions of cachexia recorded in 1981 to 1990 in the Dialysis and Transplantation Registry of a northern Italian region, Piedmont (about 4,400,000 inhabitants, 20 dialysis centers; 4,734 patients on file at December 31, 1990; yearly information on 100% of the cases). Death in conditions of cachexia increased from 105 cases in the first four years taken into account (1981 to 1984), to 107 in the last two years (1989 to 1990). Prevalence is higher in the elderly (85% of the death over age 60). Most patients (90.5%) were at high clinical risk. To assess whether the frequency of this diagnosis reflected the wide acceptance of elderly patients for dialysis and was a marked of vascular disease, a specific inquiry was conducted about 107 cachectic deaths recorded from 1989 to 1990: 82.5% of the patients had diffused vascular disease, 11.5% were already cachectic when dialysis was initiated, and 66% were in cachexia at least six months before death. Since mean age of patients dying in condition of cachexia increased from 68.8 in the period of 1981 to 1984 to 70.3 years in 1989 to 1990, and mean time on dialysis from 2.8 years in 1981 to 1984 to 70.3 years in 1989 to 1990, the higher prevalence is not likely to be due to lack of care of elderly patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetic patients on dialysis: a changing picture.

Prevalence of diabetic patients on dialysis is often considered a marker of overall acceptance rate for dialysis; however, even when acceptance policy is open, incidence of diabetic patients varies widely. Epidemiological differences of diabetes incidence all over the world partly explain the discrepancies. Incidence of diabetic patients accepted for dialysis (1981 to 82: 6 p.m.p.; 1989 to 90: 11.5 p.m.p.) differs according to age and sex in the setting analyzed (Piedmont, Northern Italian region, about 4,400,000 inhabitants, 20 dialysis centers, open acceptance since the mid-70s, yearly information on 100% of patients, gathered by a Dialysis and Transplantation Registry). Patterns changed remarkably during the 10 years considered (1981 to 90). Incidence was higher in males (10.4 p.m.p. in the period 1981 to 90), with a peak at ages 60 to 69. Incidence remained relatively stable in the younger patients, but increased in the elderly, mainly in males, rising from 6.23 in 1981 to 82 to 12.88 p.m.p. in 1989 to 90 (males, all ages). In conclusion, the demographic characteristics of diabetic patients with ESRD accepted for dialysis is changing. The stability of incidence of younger patients reassures about the open acceptance policy, at least in these ages. The increase in the elderly probably reflects the longer lifespan of diabetic patients in the overall population. The possibility of a hidden preselection must be further assessed. Future provisions of dialysis needs must take into account the trend towards an increase of this high risk, elderly population.

Heparin transfer across the rabbit peritoneal membrane.

Variable quantities of heparin have been proposed to avoid intraperitoneal clotting during peritoneal dialysis without the risk of systemic effects, because heparin is presumed to be incapable of passing through the peritoneal membrane. This study set out to verify this assumption by using labeled heparin in experimental dialysis in 7 New Zealand white rabbits. Heparin was labeled with 99mTc. Labeling quality, assessed by two chromatographic checks, showed less than 5% of free pertechnetate. Chromatographic determinations showed more than 95 and 80% of labeled heparin in inflow and outflow dialysates and in blood samples respectively. Following sodium thiopental anesthesia, animals underwent three protocols: a single 15 min cycle of time diffusion with heparin 500 U/l (A), 6 successive 15 min cycles with heparin 500 U/l (B), and a single 3 h cycle with heparin 2,500 U/l (C). Labeled heparin was found in blood organs and urine in variable percentages. The total amount of recovered radioactivity ranged from 1.5% (A) to 20% (C) of that introduced. It may be concluded that heparin passes through the peritoneum according to some law dependent on the amount used and the diffusion time.

Long-term results of CAPD in Italy: a report from the Italian CAPD Study Group.

Begun in 1979, the Italian CAPD Study Group monitored prospectively six years of CAPD experience (1980-1985) in 24 centers with 1107 end-stage renal disease (ESRD) patients (age 56.4 +/- 13.7 years). Compiled yearly, the clinical and therapeutical data were processed on a PDP 11-32 computer, according to UCLA BMPD-1L procedure. The survival rate was conditioned by age (more than 70) and by major clinical risk factors, with a large fraction of the deaths due to cardiovascular causes (40.6%) and cachexia (17.8%). The progressive reduction of peritonitis incidence (1/18.5 episodes/patient-month globally reached at the end of 1985) was due mainly to the wide spread adoption of the "Y" connection set (76% for 1985) and contributed to a decrease in drop-outs to 7.5% of 676 patients on CAPD during 1985.

Prevention and treatment of aluminum overload in uremic patients: long-term results.

The authors evaluate the efficacy of a protocol of prevention and treatment of aluminum (Al) overload in RDT patients during a 7-year period (from 1981, 164 patients, to 1987, 161 patients). Al in dialysate solutions was always less than 25 micrograms/l. Baseline Al levels greater than 100 micrograms/l were found in 22% of patients in 1981 but in none in 1987, while the percentage of values less than 60 micrograms/l increased from 55 to 91%. DFO tests were positive in 54% and 7% of cases in 1981 and 1987, respectively. A clinical diagnosis of Al intoxication was performed in 6 patients in 1981, and no further cases were diagnosed later. DFO treatment (50 mg/kg once a week) was employed preventively in 31 patients owing to positive DFO-tests, and in the 6 Al-intoxicated patients therapeutically. In the former patients none developed clinical intoxication. In the latter group clinical improvement was only temporary in the three parathyroidectomized patients. Al hydroxide [Al(OH)3] as a phosphate binder was tapered off in 1981 and substituted by Al-free chelants. In 1987, 66% of patients were given CaCO3 or Mg (OH)2 alone or in association, while 34% still needed Al(OH)3, although at low dosages (less than 2 g/day). The conclusion is that such a protocol is able to prevent and to treat cases of Al intoxication, albeit only partially.

Ten years of continuous ambulatory peritoneal dialysis: analysis of patient and technique survival.

The patient survival (PS) and technique survival (TS) were evaluated in 1990 patients on continuous ambulatory peritoneal dialysis (CAPD) (males: 55.9%, mean age +/- SD: 58.4 +/- 14.8 years), treated in 30 centers participating in the Italian PD Study Group, from 1980 to 1989 (follow-up: 3953 years; mean +/- SD: 2.02 +/- 1.86 years). The total PS was 50.7% at 4 years, compared to 73.3% of patients without clinical high-risk condition (HRC) at the beginning of CAPD. In this group (34.0%) PS was significantly higher (p < 0.001) compared, respectively, to patients with cardiovascular disease (30.5%), diabetes (13.1%), and age > or = 70 years (11.2%). The percentage of death reached the mean value of 11.3% per year without any statistically significant tendency to variation during the follow-up, despite the increased number of patients > or = 65 years old and those with HRC (p < 0.001). Cardiovascular diseases (47.3%) and cachexia (17.8%) were the most frequent causes of death, whereas the mortality due to peritonitis showed a progressive increase in patients with peritonitis incidence 1 ep/year (G4) compared to those with < 0.5 ep/year (G2). Peritonitis (0.68 ep/year) was the most frequent cause of technique failure (30.0%), with clinical complications (18.2%) and peritoneal membrane failure (16.4%) as the second and third causes. The dropout percentage was 8.3% per year with a significant decrease over time (p = 0.012) and a positive correlation with the reduction of peritonitis incidence (p = 0.035). The total TS was 50.1% at 7 years, and it was significantly worse in G4 compared to G2.(ABSTRACT TRUNCATED AT 250 WORDS)

The production of platelet-activating factor during hemodialysis.

Regenerated cellulosic membranes (CU) induced the aggregation of plasma-free human neutrophils when recirculated in a dynamic model of dialysis without the patient on the circuit. Neutrophil aggregation was linked to the production of PAF by these cells. In the absence of detectable PAF production, no neutrophil aggregation occurred, as observed during recirculation with polymethylmethacrylate (PMMA) membranes. With polycarbonate (PC), PAF production and aggregation of neutrophils were both almost half the values with CU. PAF production was studied in ten hemodialysis (HD) patients tested twice with CU and once with PC and PMMA membranes. PAF was extracted in the venous blood during filling of the dialyser for 9/20 of patients with CU (3.1 +/- 2.9 ng/ml, mean +/- 1 S.D.) a membrane that induced marked leukopenia (greater than 50% of basal values at 15 min), C3a des Arg generation (greater than 500% at 5 min), and plasma levels of the elastase-alpha 1-proteinase inhibitor complex (greater than 500% at the end of HD). Membranes such as PC and PMMA showing intermediate or low potential to induce leukopenia and C3a des Arg generation, respectively, did not trigger the production and release of PAF in detectable amounts at any interval. However, with PMMA, plasma neutrophil elastase was significantly higher than baseline at the end of dialysis. These levels were not significantly different (p less than 0.05) from those observed with CU and PC membranes.

Hypervitaminosis B12 in maintenance hemodialysis patients receiving massive supplementation of vitamin B12.

We have administered routinely a multivitamin preparation containing a megadose of B12 to 106 hemodialysis patients after dialysis treatments. We found that these patients had very high levels of serum vitamin B12 which returned to original values only after a period of three years after stopping the vitamin. Discontinuing therapy had no effect on hemoglobin, mean erythrocyte corpuscular volume, or motor nerve conduction velocity. It is not known whether maintaining a prolonged high level of vitamin B12 is harmful. However, animal and epidemiologic studies have suggested that both cobalamin and cobalt may be potentially toxic. In view of the absence of demonstrable benefit and the possible risk of toxicity, we believe that the use of such megadose vitamin compounds in dialysis patients should be re-evaluated.

Well being in patients on CAPD and hemodialysis.

In the present multicenter study, 120 pts who had been treated by both hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) for at least 6 months each, were invited to answer questions on 34 matters, to compare symptoms and their well-being while on the two treatments. Patients were invited to choose HD or CAPD and indicate the reasons for their choice. For 28 patients the first treatment was HD and for 92 CAPD. The mean time between the change of therapy and the study was 46 +/- 35 months. Their final choices were found to be strictly related to the present treatment (p < 0.001). The reasons for choice of CAPD were: more free time (21%), more freedom (67%), better well-being (44%), less worry (5%); for HD they were: more free time (53%), better well-being (39%), less worry (13%), no need for a peritoneal catheter and fewer clinical complications (19%). The catheter was considered more cumbersome than the A.V. fistula, the time involved was considered to be shorter on HD by 52 patients and on CAPD by 39, thirst and cramps were considered to be more frequent and severe on CAPD by half of the patients. The prevalence and severity of problems and symptoms and choice of treatment were not related to sex, job, education or age.

[Analysis of cause of death in the 1st and last periods of the Piedmontese Dialysis and Transplantation Registry]. / Analisi delle cause di morte nel primo e nell'ultimo periodo del Registro Piemontese di Dialisi e Trapianto (RPDT).

The aim of this study is to assess the mortality causes in dialysis in the Piedmont Region, using the data of the Dialysis and Transplantation Register (DTR). Data of a 15-year use of the DTR regarding 5519 hospital dialysis admissions were considered. Mortality seems to be particularly due to cardiac causes analyzing, also the incidence of other causes of death such as: cachexia, sudden death and infection causes.

[Long-term results of high-tolerance extracorporeal methods in the light of the new high-efficiency treatments]. / Risultati a lungo termine delle metodiche extracorporee ad alta tolleranza alla luce dei nuovi trattamenti ad alta efficienza.

While the efficiency of treatment has been recently related to long-term clinical outcome, the relevance of tolerance on this subject, even on critically ill patients, has seldom been evaluated, for the limited size of single pools on high tolerance dialytic treatments (HTT) and the flux of pts. among treatments. Since 1981, on 2243 pts on files of the Dialytic Piedmont Regional Registry, 1399 treatments on acetate-hemodialysis (HD), 1153 on bicarbonate dialysis (BC) and 249 hemofiltration (HF) were compared by survival analysis (Mantel test) and yearly hospitalization rate (YH), according to age, factors of clinical high risk (HR) and presence of diabetes. BC and HF showed on HR pts. LTS comparable to HD (at 1 yr. 82, 78.3 vs 76.77%) despite the higher age, and the lower proportion of first choice (38.9%, 25% vs. 83.5%) testifying successful treatment of more critical cases. On non HR pts. HF, a less efficient treatment vs BD and AD, showed slightly reduced LTS (95.2% at 1 yr. vs. 98.1 and 97.9%). HY results higher on HF vs. BD on non HR pts. (10.4 vs. 5.3 and 2.1%) but improves on HR pts. (10.7 vs. 12.5%) and is lower than BC on diabetics (8.3 vs. 14.5%) (p less than 0.01).

[Clinical and epidemiologic characteristics of selected long-term survivors undergoing dialysis]. / Caratteristiche cliniche ed epidemiologiche di pazienti selezionati da una lunga sopravvivenza in dialisi.

At the end of December, 1993, 389 patients treated by means of dialysis for more than 15 years were registered in the Piedmont Dialysis and Transplantation Register; among them, 183 were alive. Characteristics of these patients as age at the beginning of dialytic treatment, casual nephropathies, causes of death, high risk conditions, dialytic schedules, vascular access, hospitalization requirements, rehabilitation, dialysis efficacy, gross mortality, were compared with those of patients treated for a shorter time, concluding that a very long dialytic survival can be achieved with a good clinical and social rehabilitation.

[Vascular access for chronic hemodialysis: current status and new directions in the Piedmont]. / Accessi vascolari per emodialisi cronica: situazione attuale e nuovi orientamenti in Piemonte.

Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.

[Comorbidity factors in the dialysis registries and the experience of the Piedmontese Registry]. / I fattori di comorbidità nei Registri di Dialisi e nell'esperienza del Registro Piemontese.

The parameters used at present by the Dialysis and Transplant Registries of various countries to evaluate dialyzed patients' comorbidity show great differences, mostly owing to the different epidemiological, social and racial characteristics of the studied populations. Moreover, the typology of the dialyzed patient is changing: the mean age is increasing, patients with high-risk conditions as vasculopathy and diabetes are widely accepted to the treatment. Thus the Piedmont Registry will be implemented as follows: new fields about comorbidity for clinical (blindness, cachexy and dementia), social (smoking, alcohol and drugs addiction) and diagnostic (type of diabetes, of neoplasm, of cardiovascular problem) parameters, and questions needing dichotomic response (vasculopathy yes or no) will be added. The exact time of appearance of any risk factor will be requested, and a field for "others" risk factors will be added as well, trying to deeply identify the dialytic population not affected by any comorbidity factor. Finally, a new improved control system of the collected data will be used: our registry needs to be implemented in the future by such evaluations, to go on giving useful informations about epidemiology of the dialyzed patients.

[Critical review of renal transplantation data from the Piedmontese Regional Dialysis and Transplantation Registry]. / Revisione critica dei dati riguardanti il trapianto renale nel Registro Regionale Piemontese di Dialisi e Trapianto (RPDT).

On 31/12/1995 a total of 1,128 Piedmontese uremic patients had undergone kidney transplantation, with 65% of operations performed by the Regional Reference Centre and 35% by extra-regional centres. Waiting time for dialysis was less than 5 years in over half of the patients most of whom were aged between 40 and 60 years old. In overall terms, the patient survival rate was 94%, 87%, 75% at 24, 60, 120 months respectively, with a statistically significant improvement when the curve was evaluated in the patient-pool treated with cyclosporine (84% versus 87% at 7 years). Organ survival was 76% at 21 years and 42% at 10 years, and results were again improved by the use of cyclosporine. Pathologies affecting the transplanted organ represent the main cause of morbidity; drop-out during dialysis is caused above all by immunological diseases. Infectious pathologies were responsible for the majority of deaths in this population.

[Uremic pruritus]. / Il prurito uremico.

Among the various dermatologic abnormalities that can be associated with advanced chronic renal failure and dialysis therapy, pruritus is certainly the most disturbing disorder. Pruritus is an unpleasant, vexing sensation that provokes an intense desire to scratch. In the past the pruritus was considered from the neurophysiologic point of view as a submodality of pain, but more recent research showed that pain and pruritus are sensations which are carried through different populations of primary sensory neurons. The causes of pruritus in uremic patients are still unknown: xerosis, intradermic microprecipitation of divalent ions, hyperparathyroidism, peripheral neuropathy, allergic reactions and hypersensitivity, histamine and others have been considered as pathogenetic factors. The uncertainty on the causes is in part responsible for the different approach and results, unsatisfactory in many cases. In this paper we will review the neurophysiology, the pathogenesis and the possible therapeutic approaches to uremic pruritus.