[The Early Years of Nephrology at Molinette Hospital in Turin Told by Those Who Lived and Built Them].

This article, written by several authors, describes the birth and early development of the nephrology at Molinette Hospital in Torino, Italy. In particular, it supplies important information on Antonio Vercellone, very motivated and innovative clinician and one of the fathers of Italian nephrology, and on Giuseppe Piccoli, his right-hand man and then his successor. This article also shows the strong professional and human engagement that was requested to the young doctors who, in the early Sixties and Seventies of the past century, had chosen to devote their professional lives to the patients with kidney diseases: from endless workdays without schedules to the anguish caused by the shortage of artificial kidneys to the cure of very fragile and unfortunate patients, and much more.

Chronic kidney disease certification process manual by the Italian Society of Nephrology (SIN): part II: programme management and clinical information management.

This is the second part of a document describing a voluntary certification process based on Joint Commission International (JCI) criteria developed by the Italian Society of Nephrology (SIN) and JCI representatives. In the first part we discussed standards for clinical care delivery and performance measurements related to chronic kidney disease care. Herein (Part II), we complete the description of Performace measurements and CKD care by describing issues related the management and clinical information management.

Chronic kidney disease certification process manual by the Italian Society of Nephrology (SIN): Part I: clinical care delivery and performance measurements and improvement.

Chronic kidney diseases (CKD) has now emerged as a public health priority, and there is an increasing demand by patients and health care organisations that the quality of care delivered by renal units to CKD patients be systematically monitored and evaluated. The Italian Society of Nephrology (SIN) has started an initiative aimed at promoting a quality certification process specifically focused on CKD. To this end, SIN started a collaboration with an independent Italian company which is a partner of Joint Commission International (JCI), a nonprofit international organisation dedicated to the promotion of quality improvement and safety of health services. As a result of this collaboration, a document describing a voluntary certification process developed based on JCI criteria was produced by SIN. This document comprises 2 parts. Herein (Part I) we deal with standards for clinical care delivery and performance measurements related to CKD care. Programme management and clinical information management will be presented in a separate manuscript (Part II).

Current structure and organization for renal patient assistance in Italy.

BACKGROUND: Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) has compiled a national census of Renal Units (RU) existing in the twenty Italian regions related to the year 2004. METHODS: An on-line questionnaire including 158 items explored structural and human resources, organization aspects, activities and epidemiological data in SIN, 2004. RESULTS: The census identified 363 public RU, 303 satellite Dialysis Centres (DC) and 295 private DC totalling 961 DC [16.4 per million population (pmp)]. The inpatient renal beds were 2742 (47 pmp). Renal and dialysis activity was performed by 3728 physicians (64 pmp), of whom 2964 (80%) were nephrologists. There was no permanent medical assistance in 41% of satellite DC. There were 1802 renal admissions pmp and 99 renal biopsies pmp. The management of acute renal failure (13 456 cases; 230 pmp) represented a relevant proportion of the activities conducted in public RU. In 2004 there were 9858 new cases of end-stage kidney disease requiring renal replacement therapy (RRT) (169 pmp). On 31 December 2004, 60 058 patients were on RRT (1027 pmp), 43 293 of which (740 pmp) were on dialysis and 16 765 (287 pmp) with renal graft. CONCLUSIONS: This census of the Italian RU and DC in 2004 provides decision makers and healthcare stakeholders with detailed data for benchmarking and has financial implications for the public health system. Similar analyses may be conducted in other countries permitting standardization of medical and cost-related aspects of renal care.

Analysis of the factors conditioning the diffusion of peritoneal dialysis in Italy.

BACKGROUND: The diffusion of peritoneal dialysis (PD) in Italy is lower than expected on the basis of indications and contraindications reported in literature. METHODS: To analyse the factors influencing the use of PD in Italy, we used data from the first National Census of the Italian Society of Nephrology relating to 9773 incident patients (Incid(HD + PD)) in 2004 and 43 293 prevalent patients dialysed in 658 centres at 31/12/2004 (337 public centres, 286 private centres, 12 paediatric centres, 15 research or religious institutions and 8 unspecified). RESULTS: The percentages on PD of total incident (Inc(PD)%) and prevalent dialysis patients (Prev(PD)%) were 15.9% and 10.3%, respectively with considerable variations from region to region and from centre to centre. The Inc(PD)% was higher in regions with fewer patients on dialysis in private centres. In the private centres, the Inc(PD)% was 0.4%. Of the 325 non-paediatric public centres, 116 (35.7%) do not use PD: compared with the 209 centres which do, these centres have a lower mean Inc(HD + PD) and Prev(HD + PD) per centre (13.0 +/- 12.3 vs 28.6 +/- 18.0 - 51.8 +/- 35.7 vs 117.3 +/- 66.4 patients, P < 0.0001), and more haemodialysis (HD) stations available (3.0 vs 3.5 patients per HD station, P < 0.0001). However, the significant influence of cultural and motivational factors on the use of this method is demonstrated by the fact that it is used by 34% of the smaller non-paediatric public centres, and is not used by 19% of the larger non-pediatric public centres.

Glucose infusion test (GIT) compared with the saline dilution technology in recirculation measurements.

BACKGROUND: Glucose infusion test (GIT) is a new method to measure vascular access recirculation (R) based on basal glucose increase in the arterial blood line after a 20% glucose bolus (5 ml) into the venous chamber. METHODS: We compared GIT with the ultrasound dilution method (HD01, Transonic Systems Inc., USA) in a circuit reproducing in vitro the phenomenon of R. We repeated the comparison in 162 chronic haemodialysis patients (133 fistulae, 17 central venous catheters, 12 prosthetic grafts). RESULTS: In vitro, we determined the timing for C2 sampling: QB 200 ml/min, C2 16-20 s; QB 300 ml/min, C2 13-17 s; QB 400 ml/min, C2 9-12 s. GIT showed no false positives nor false negatives (100% specificity and sensitivity) while HD01 did not recognize three cases with R=5% (91% sensitivity) and it yielded no false positive (100% specificity). The Bland-Altman analysis showed a bias of 0.2+/-1.3% and 1.3+/-2.9% for GIT and HD01, respectively. In vivo, only 16 out of 162 patients were found positive with both methods (GIT 13.5+/-13%; HD01 16.3+/-15%; P=NS) while three patients with minimal R (GIT 3.2%) were not recognized by HD01 although a low R peak was clearly evident and repeatable on the laptop plot. The Bland-Altman analysis showed an overall bias of 0.2+/-1.7% to the limits of agreement=-3.1 and 3.6% (n=162) and no correlation between the difference and the mean of positive tests. The pooled coefficient of variation of positive cases was 13.3 and 18.1% for GIT and HD01, respectively. DISCUSSION: Our in vitro study showed a good performance of GIT and its better sensitivity compared to HD01. These results were confirmed in vivo with only 3/162 discordant results due to a low R under the HD01 limit of detection (R=5%). In conclusion, the GIT proved to be a very accurate screening test for R, with a very low threshold of detection. In addition, it is simple, user-friendly and inexpensive.

Comparison of glucose pump test and urea test in measuring blood access flow.

BACKGROUND: The Glucose Pump Test (GPT) is a new method for measuring the access blood flow (Qa) based on a constant glucose infusion (Qi), with known glucose concentration (Ci), in the arterial needle and on glucose determination in two blood samples from the venous needle, the first (C1) in basal conditions, the second (C2) during the infusion. Qa depends on the difference in glucose between the two samples and is computed from the formula: QaGPT = Qi x (Ci-C2)/(C2-C1). METHODS: The new method, previously evaluated by ultrasound dilution and color-Doppler techniques, was compared with the Urea Test (UT) in 20 patients measuring recirculation (R) during reversal of the arterial and venous needles (QaUT = Qb x (1/R -1)). All Qa determinations were done twice by both methods. Glucose and urea were determined respectively two and three times. RESULTS: Mean QaGPT = 841, SD 347 ml/min, mean QaUT = 872, SD 417 ml/min (p = n.s.); mean percent difference QaGPT-QaUT= 16%, SD 14; mean coefficients of variation of paired determinations: 8.1% and 12.1% respectively; Pearson coefficient between the two methods: r= 0.91. CONCLUSIONS: The comparison showed a good correlation between the two methods and similar mean values. The coefficient of variation of the new method was acceptable and lower than with the UT. The GPT is a reliable technique for measuring blood flow in vascular accesses.

The Diamant Alpin Dialysis cohort study: clinico-biological characteristics and cardiovascular genetic risk profile of incident patients.

BACKGROUND: Clinical and therapeutic characteristics of chronic dialysis patients vary widely at national and/or regional levels. Their increased cardiovascular (CV) mortality is not explained by traditional cardiovascular disease (CVD) risk factors only. Therefore, this study aimed to investigate and compare the characteristics of patients starting dialysis in a homogeneous Alpin region and possibly to identify new biological parameters (phenotypes or genotypes), which eould be responsible for the increased CVD seen in end-stage renal disease (ESRD) patients. METHODS: A cohort of 279 non-selected consecutive patients entering a dialysis program was prospectively investigated in eight centers of three adjacent regions in France, Italy and Switzerland. In addition to the usual demographic, clinical and biological data, we analyzed at study entry the blood levels of homocysteine, lipoprotein(a) (Lp(a)) and antioxidized low density lipoprotein (LDL) antibodies, vitamin B12 status, Lp(a) and haptoglobin phenotypes, methylenetetrahydrofolate reductase (MTHFR), angiotensin-converting enzyme (ACE), allele epsilon E4 of apolipoprotein (ApoE4) and plasminogen activator inhibitor-1 (PAI-1) genetic polymorphism. RESULTS: At entry, 90.3% of patients were hypertensive, 30% had type 2 diabetes mellitus and 17.6% were current smokers; 42% of patients had already experienced at least one CV event: peripheral artery disease (26% of the cohort), coronary artery disease (22%) or ischemic cerebro-vascular disease (16%). Forty-two patients had had > or =2 CV events or documented atherosclerotic localizations. Anemia was not optimally treated: mean hemoglobin (Hb) was at 97.7 g/L and, while overall 62% of patients received erythropoietin (EPO) prior to dialysis, large national differences were observed. Compared to the reference population, ESRD patients exhibited increased homocysteinemia, Lp(a) levels and ApoE4 allele prevalence. Conversely, the distribution of Lp(a) phenotype, MTHFR TT, ACE DD and PAI-1 4G/4G was equivalent to that of the reference population. In addition, none of the analyzed phenotypical or genotypical parameters, except for the haptoglobin 2.2 phenotype, could be associated with the existence of a previous adverse CV event. CONCLUSIONS: (1) The clinical characteristics of the ESRD patients entering dialysis in our region were comparable to the currently observed dialysis populations in most European countries with the deleterious role of advancing age, diabetes, previous CVD, smoking and hypertension evident (2). Except for anemia therapy, there were no regional or national differences observed at dialysis start. (3) An analysis of the phenotypic and genotypic CV risk factors demonstrated differences with the reference population only for hyperhomocysteinemia, Lp(a) and ApoE4 allele prevalence, with no notable differences among the participating centers.

Glucose pump test: a new method for blood flow measurements.

BACKGROUND: A good test for monitoring blood flow (Q(a)) must be accurate, rapid and economical in order to allow frequent easy measurements. The glucose pump test (GPT) is based on a constant glucose infusion as a dilutional indicator of Q(a). METHODS: GPT protocol requires a constant glucose infusion, by a syringe pump, into the arterial needle and two blood withdrawals from the venous needle, one basal before the infusion (C(a1)), the other (C(a2)) 11 s after the start of the infusion. At the bedside we measure glucose on C(a1) and C(a2). Knowing the infused glucose concentration (C(i)) and the pump infusion rate (Q(i)) we can easily calculate Q(a)=Q(i)x(C(i)-C(a2))/(C(a2)-C(a1)). We verified the accuracy of this new method by comparing it with the in vitro results from a circuit reproducing vascular access circulation, and in vivo comparing GPT-Q(a) with Doppler ultrasound in pre-dialysis to the Transonic HD01-Q(a) during dialysis in 23 chronic haemodialysis patients. RESULTS: GPT-Q(a) values were highly correlated with the in vitro Q(a)=1.01 x GPT-Q(a)-16.6; r=0.94. There was agreement between the mean flow values of GPT and Doppler (927.5 and 927.1 ml/min, respectively; P=NS) while the mean value of HD01 was significantly lower (HD01-Q(a)=690 ml/min; P<0.001 vs GPT-Q(a) and Doppler-Q(a)). The regression analysis showed a good correlation between GPT and Transonic results (r=0.95; HD01-Q(a)=0.86 x GPT-Q(a)-111.9), while there was a significant difference between the two measurements (mean Delta 235+/-117 ml/min; range from 15 to 451 ml/min). This difference could be caused by the large haemodynamic variations (different blood pressure, cardiac output, circulating effective volume, haematocrit) between pre-dialysis and intra-dialysis and in addition by the counter current flow during the reversal blood lines Transonic measurements. CONCLUSIONS: GPT offers the advantage of a simple bedside procedure easily performed before dialysis: it does not interfere with the dialysis treatment and it is less intrusive for the patient as it does not involve reversal of the blood lines. The preliminary data indicate that our method could be a useful, simple and cheap test for monitoring access flow in every dialysis unit.

Daily Dialysis: Toward a New Standard in Well-Being.

Daily hemodialysis (DHD) is a promising option; however, logistic obstacles and clinical perplexities limit its dissemination. Understanding the mechanisms of, and the time until, the onset of improved well-being may help to quantify clinical advantages and to define the minimum length of a "trial" of daily dialysis. By following 30 patients treated in 4 centers, this study aimed to determine how long a period of time is needed until a patient experiences subjective improvement. From November 1998 to November 2000, 30 patients tried at least 2 weeks of short daily dialysis in four Northern Italian centers of Piemonte and Valle d'Aosta. The DHD (2 - 3 hours; blood flow 270 - 350 mL/min; individual HCO3 , Na, K) was performed at home or in a center. Motivations to try DHD, fears and concerns regarding DHD, and changes in perceived well-being were assessed by semi-structured interview. The main clinical indications for a trial of DHD were poor tolerance of conventional treatment, cardiovascular disease, and hypertension or hypotension; only 6 patients had no comorbidity at start. The patients' main reasons for choosing DHD were related to job problems and the search for a better treatment. Most of the patients continued DHD because of improved well-being; logistic reasons accounted for the drop-outs (5 patients). The main fears were related to logistic aspects, vascular access problems, and excessive involvement of the partner on home dialysis. Improved well-being was reported by 28 of 30 patients; 2 patients reported no difference. Subjective improvement was perceived within 2 weeks in 22 of 30 patients, and within 1 month in 28 of 30 patients. An offer of a 2 - 4 week trial of DHD may help patients and caregivers to determine whether subjective and objective benefits outweigh logistic problems and whether a permanent transfer to DHD is worthwhile.