[Home Hemodialysis: new organizational models to favor the economic and environmental sustainability in the province of Belluno].

The prevalence of chronic kidney disease is 7.05% in Italy. The replacement dialysis treatments determine greenhouse gas emissions thus contributing to climate change, an important source of risk to global health. Furthermore, the percentage of the Italian Gross Domestic Product destined to public health expenditure has progressively contracted. The province of Belluno has an area of 3610 km2, with a population density of 56 people/km2, an old age index of 248.5, and offers 4 dialysis centers; however, several patients take up to 8 hours/week to commute to the dialysis center, with a consequent significant environmental and economic impact. We have investigated the Home Hemodialysis (H-HD) models, both as Assisted Home Hemodialysis (AH-HD), and as Not-assisted Home Hemodialysis (NH-HD), to evaluate their environmental and economic sustainability, and the actual impact due to their adoption by 5 patients. Thanks to AH-HD it is possible a reduction up to 3767 kg of CO2 per year, and an economic saving of € 32 456 per year. Utilizing a NH-HD treatment, it is possible a reduction of 5330 kg of CO2 per year, and a reduction in annual healthcare costs up to € 30 156 per year. Furthermore, the adoption of H-HD treatment for 5 patients allowed an effective reduction of 14 537 kg of CO2 emitted and a net economic saving of € 57 975. Therefore, we consider H-HD methods a valid option for patients living in areas with low population density, where transports have a significant impact, allowing a net reduction of CO2 equivalent emissions and a considerable saving of the health resources.

[Lithium poisoning: neurological signs, nephrological therapy]. / Intossicazione da litio: clinica neurologica, terapia nefrologica.

Lithium is an effective drug in the treatment of bipolar disorder and other psychiatric and neurological diseases. Unfortunately, its therapeutic index is narrow. There are three types of lithium poisoning: acute poisoning (in untreated patients), acute on chronic poisoning, when an overdose is taken accidentally or with suicidal intent, in patients under treatment and chronic poisoning (patient treated with lithium) when drug intake is correct but excessive in relation to its elimination (increased dose or more often reduced clearance) resulting in lithium overload. In this last condition, the clinical presentation is primary neurological while therapy involves the nephrologist provided that lithium clearance is mainly renal and hemodialysis is the most effective method for removal.

[Radiographic disappearance of lanthanum]. / Il carbonato di lantanio in polvere si nasconde alla radiografia dell'addome.

In 2006, Cerny and Kunzendorf in the New England Journal of Medicine Images in clinical medicine, showed the radiographic appearance of lanthanum for the first time. After many years we noticed the inverse phenomenon. In a peritoneal dialysis patient treated with lanthanum carbonate, we had two radiography of the abdomen for monitoring the peritoneal catheter. In the first radiography contrast material was seen in colon. In the most recent radiography contrast material disappeared. The patient was always taking the same dose of lanthanum carbonate (1000 mg bid), although at the time of the first radiography he took the chewable tablets, for the last radiography he took the new powder formulation. We found a report in literature highlighting this phenomenon meanwhile indicating a greater chelating effect for the powder. Our hypothesis is that despite the same lanthanum dose, powder provides a greater surface area of binding and a more dispersed bowel distribution to explain a masked radio-opacity. Considering the wide availability of the powder, this must be taken into account especially in evaluating therapeutic compliance.

[Renal biopsy in the lateral position in high risk patients: an opportunity to take advantage of]. / La biopsia renale in decubito laterale nei pazienti complessi: una possibilità da sfruttare.

Percutaneous ultrasound-guided renal biopsy (RB) is the gold standard for diagnosis of renal diseases. The standard procedure involves biopsy in the prone position (PP) for the native kidneys. In high risk patients, transjugular and laparoscopic RB have been proposed. In patients suffering from obesity or respiratory diseases, the RB of the native kidney in the supine anterolateral position (SALP) represents an alternative to these invasive and expensive methods. We illustrate the technique of execution of RB in the lateral position (LP) on native kidneys. The procedure is safe, effective and has reduced the path travelled by the needle biopsy compared with PP and SALP.

Equivalence of information from single frequency v. bioimpedance spectroscopy in bodybuilders.

In bioelectrical impedance spectroscopy (BIS), it is assumed that the current path is only extracellular at the lowest frequencies and that it is both extra- and intracellular at the highest frequencies. We tested validity of BIS assumptions in bodybuilders who have an increased intracellular volume due to hypertrophy of muscle fibres. The study was observational cross-sectional in a study group of thirty professional bodybuilders compared with thirty control subjects. Resistance (R) and reactance (Xc) vector components fitting the Cole's arc with BIS (SFB3 analyser) were compared with components at 50 kHz frequency. The average Cole's arc in bodybuilders was significantly smaller and shifted to the left in the R-Xc plane (both R and Xc values were smaller at any individual frequency). The ratio of Xc at 5 kHz and Xc at the characteristic frequency was 70% in bodybuilders and 64% in control subjects, indicating a huge intracellular flow of the electric current at low frequencies in both groups (expected ratio close to 0 if the current path was extracellular). As a consequence of a common path, the correlation coefficient between R values at 50 kHz and at other frequencies (from 0 to infinity) was 0.94 to 1.00. The correlation between total body water estimated with BIS or with R at 50 kHz was 0.98. Hence, there was equivalence between information provided by the vector components R and Xc at 50 kHz and that provided by 496 correlated vectors that were measured with BIS.

Anti-renin-angiotensin-system drugs and development of anemia in chronic kidney disease.

BACKGROUND: A variable inhibition of erythropoiesis has been reported in uremic patients with renal anemia receiving anti-renin-angiotensin-system (RAS) drugs (angiotensin-converting-enzyme inhibitors, and angiotensin-receptor-antagonists). The time to development of renal anemia before dialysis is still unknown. METHODS: A retrospective cohort study (1 to 15 years) on records of 327 out-patients (217 males, 110 females) without anemia and with chronic renal insufficiency (creatinine clearance 16 to 75 mL/min) was conducted to estimate the time to development of renal anemia (Hb < 11.5 g/dL in females and Hb < 12.5 g/dL in men), and the time to decrease of Hb by 1 and 2 g/dL or more, irrespective of anemia development. Two treatment groups were analyzed: 142 patients with, and 185 without anti-RAS drugs. RESULTS: Median survival time to development of anemia was 81 months, 59 months to the loss of Hb > 1 g/dL, and 94 months for the loss of Hb > 2 g/dL. Anemia developed significantly earlier in patients with initial Ccr < 40 mL/min and in those with initial Hb < 14 g/dL. In the multivariate analysis (Cox model), male gender, Ccr < 40 mL/min, and Hb < 14 g/dL, in increasing order of relative risk, significantly contributed to prediction of anemia development without any influence of the treatment with anti-RAS drugs. The same results were obtained considering survival to the loss of either Hb > 1 g/dL or Hb > 2 g/dL. CONCLUSIONS: Development of renal anemia in mild to severe chronic kidney disease is not influenced by treatment with anti-RAS drugs.

Aspergillus fumigatus peritonitis in ambulatory peritoneal dialysis: a case report and notes on the therapeutic approach.

Aspergillus peritonitis is a rare disease in continuous peritoneal dialysis. It is a severe form of peritonitis, which is frequently lethal. We report a case of Aspergillus fumigatus peritonitis in a female patient on automated peritoneal dialysis (APD), who was successfully treated with intravenous amphotericin B and the removal of the peritoneal catheter. As delayed treatment has an increased mortality rate, it is mandatory to remove the catheter and to start intravenous treatment with amphotericin B empirically.

Equivalence of information from single versus multiple frequency bioimpedance vector analysis in hemodialysis.

BACKGROUND: In suspended cells, low-frequency current only passes through extracellular fluids, while current at higher frequencies passes through extra- and intracellular fluids. Cells in soft tissues are in contact with each other, which causes tissue anisotropy, meaning that impedance changes along different cell directions, with part of low-frequency current also passing through cells. Hence, equivalent information on body impedance change is expected at all frequencies, which we proved in a dynamic condition of fluid removal with hemodialysis. METHODS: We performed whole-body impedance spectroscopy (496 frequencies from 4 to 1024 kHz, SEAC SFB3 analyzer; Brisbane, Australia) before and during fluid removal (0, 60, 120, 180 min, 2.5 kg) in 67 hemodialysis patients. With increasing current frequency, resistance (R) decreases and reactance (Xc) moves along the Cole's semicircle on the R-Xc plane. RESULTS: The Cole's semicircles progressively enlarged and moved to the right on the R-Xc plane following fluid removal (increase in both R and Xc values at any given frequency). Xc values at 5 kHz (expected values close to 0 Ohm) were 70% of the maximun Xc, indicating an intracellular current flows at low frequencies. The correlation coefficient between R at 50 kHz (standard frequency) and R at other frequencies ranged from 0.96 to 0.99, and the correlation coefficient between Xc at 50 kHz and Xc at other frequencies at any time point ranged from 0.65 to 0.99. CONCLUSION: From high Xc values at low frequency, tissue anisotropy is inferred. Intra- and extracellular current flow causes equivalence of information based on functions of R and Xc measurements made at 50 kHz versus other frequencies.

Double urine circulation: importance of pores.

The authors examine a presentation to the Royal Academy of Sciences of Paris by L. Morin, French physician and meteorologist. In this communication the presence of "pores" in the stomach and the bladder, which would allow a quick elimination of the urines on the occasion of an abundant fluid intake.

Subcutaneous epoetin-alpha every one, two, and three weeks in renal anemia.

BACKGROUND: The same epoetin dose administered subcutaneously (SC) once weekly instead of thrice or twice weekly to patients with renal anemia is reported to be equally effective. The aim of this study was to verify whether a target hemoglobin (Hb) could be maintained with SC epoetin administered at longer intervals - every one, two or three weeks. METHODS: This was a single-center, retrospective cohort study on 67 consecutive outpatients (35 adult caucasian males) with anemia secondary to chronic renal insufficiency, all in follow-up for at least 12 months, who maintained the target Hb of 11 to 13 g/dL for six months with one SC injection of 10,000 U epoetin-alpha every five days (14,000 U/wk), or every one (Epo/1, 10,000 U/wk), two (Epo/2, 5,000 U/wk) or three weeks (Epo/3, 3,333 U/wk) according to their Hb concentrations after the induction phase. RESULTS: The target Hb > or = 11 g/dL was maintained over six months of treatment with SC epoetin > 10,000 U/week in 4 patients (6.0%, 95% CI 1.5-14.6) and with SC epoetin < or = 10,000 U/week in 63 patients (94.0%, 95% CI 85.4-98.4). Among the latter, 16 (25.4 %, 95% CI 15.3-37.9) maintained the target with Epo/1, 25 (39.7 %, 95% CI 27.6 to 52.8) with Epo/2, and 22 (34.9 %, 95% CI 23.3 to 48.0) with the Epo/3 regimen. On average, they received 5,688 U/week (86.2 U/kg/week) and the expected number of injections was 30 per year. CONCLUSIONS: Epoetin 10,000 U SC every two or three weeks maintained the target Hb concentration of 11-13 g/dL over a six month period in 75% of patients. Prospective, randomized and controlled trials are needed to establish the validity of this simplified regimen.