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.

Acetate-free biofiltration.

Acetate-free biofiltration (AFB) is a hemodiafiltration technique that, technically as well as biologically speaking, has all the premises for being a perfectly biocompatible technique capable of satisfying even the demands of critical patients laden with comorbidities. Important clinical benefits to patients have been reported, such as a better correction of acid-base balance, an improved nutritional status and a better hemodynamic stability. In particular, as far as the cardiovascular instability is concerned, several studies have shown that the rationale behind a better hemodynamic stability is the overall absence of acetate usually present in the dialysis bath, which often leads to an impaired vascular tone and a reduced cardiac contractility. One of the powerful features of AFB is its adaptability to new devices and tools which can be easily and safely used. In AFB, potassium modulation in the dialysate is easily achieved. Thus, patients with elevated levels of predialysis potassium and a tendency to develop both intra- and interdialysis arrhythmias benefit most. Lastly, the possibility to associate AFB with devices like Hemocontrol (which allows for a feedback conditioning of blood volume) broadens its practical scope, not only for use with hypotension-prone patients, but also with hypertensive patients with massive increases in their interdialysis body weight. In this category of patients, avoiding the risk of dangerous hypovolemias allows for the achievement of dry body weight, thereby facilitating the control of arterial blood pressure and minimizing the clinical consequences of a chronic fluid overload.