Vascular access for hemodialysis in Italy: What a national survey reveals.

BACKGROUND: Since in Italy there are no official data on vascular access (VA) for hemodialysis the Vascular Access Project Group (VAPG) of the Italian Society of Nephrology (SIN) designed a national survey. METHODS: A 35-question survey was designed and sent it to the Italian facilities through the SIN website. The basic questions were the prevalence, the location, and the surveillance of VA, the bedside use of ultrasound, the use of fluoroscopy for central venous catheter (CVC) placement, and of buttonhole technique, the role of nephrologist in the access creation. RESULT: The questionnaire was completed in June 2022 by 161 facilities. The survey registered 15,499 patients, approximately one-third of the Italian dialysis population. The prevalence of arteriovenous fistula (AVF), arteriovenous Graft (AVG), and CVC were 61.8%, 3.7%, and 34.5% respectively. The AVF location was 50% in distal forearm, 20% in meanproximal forearm, 30% in upper arm. For AVF creation, nephrologists were involved in 72% of facilities while for CVC placement in 62%. As regards VA monitoring, 21% of the facilities did not have a surveillance protocol; 60% did not register AVF thrombosis and 53% did not register CVC infections. Most of facilities use the fluoroscope during CVC placement, 37% when needed, and 22% never. Ultrasound-guided puncture of complex AVFs was used by 80% of facilities. Buttonhole puncture was used in 5% of patients. CONCLUSIONS: Some considerations emerge from the survey data: (1) The increasing CVC prevalence compared to DOPPS 5 study. (2) The low rate of AVG prevalence. (3) The nephrologist is the operator in many VA procedures. (4) The fluoroscopy for CVC placement and the US-guide puncture of the complex AVF are widely used in most facilities. (5) The practice of the buttonhole is not widespread. (6) When the operator is the nephrologist more distal fistulas are performed.

Primary membranous nephropathy in the Italian region of Emilia Romagna: results of a multicenter study with extended follow-up.

BACKGROUND: Since primary membranous nephropathy is a heterogeneous disease with variable outcomes and multiple possible therapeutic approaches, all 13 Nephrology Units of the Italian region Emilia Romagna decided to analyze their experience in the management of this challenging glomerular disease. METHODS: We retrospectively studied 205 consecutive adult patients affected by biopsy-proven primary membranous nephropathy, recruited from January 2010 through December 2017. The primary outcome was patient and renal survival. The secondary outcome was the rate of complete remission and partial remission of proteinuria. Relapse incidence, treatment patterns and adverse events were also assessed. RESULTS: Median (IQR) follow-up was 36 (24-60) months. Overall patient and renal survival were 87.4% after 5 years. At the end of follow-up, 83 patients (40%) had complete remission and 72 patients (35%) had partial remission. Among responders, less than a quarter (23%) relapsed. Most patients (83%) underwent immunosuppressive therapy within 6 months of biopsy. A cyclic regimen of corticosteroid and cytotoxic agents was the most commonly used treatment schedule (63%), followed by rituximab (28%). Multivariable analysis showed that the cyclic regimen significantly correlates with complete remission (odds ratio 0.26; 95% CI 0.08-0.79) when compared to rituximab (p < 0.05). CONCLUSIONS: In our large study, both short- and long-term outcomes were positive and consistent with those published in the literature. Our data suggest that the use of immunosuppressive therapy within the first 6 months after biopsy appears to be a winning strategy, and that the cyclic regimen also warrants a prominent role in primary membranous nephropathy treatment, since definitive proof of rituximab superiority is lacking.

Methicillin-Resistant Staphylococcus aureus Peritonitis due to Hematogenous Dissemination from Central Venous Catheter in a Maintenance Dialysis Patient.

Staphylococcus aureus is a Gram-positive bacterium commonly associated with severe infections in hospitalized patients. S. aureus produces many virulence factors leading to local and distant pathological processes. Invasiveness of S. aureus generally induces metastatic infections such as bacteremia, infective endocarditis, osteomyelitis, arthritis, and endophthalmitis. Peritoneal localization from extra-abdominal infection can be a potential consequence of S. aureus infection. Two cases of metastatic peritonitis have been described in patients on peritoneal dialysis with concomitant peripheral vascular catheter-related bloodstream infection. We reported a case of peritoneal metastatic infection caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient on maintenance hemodialysis. A 37-year-old man was admitted with fever and chill due to jugular central vascular catheter (CVC)-related bloodstream infection caused by MRSA. CVC was placed after switching the patient from peritoneal dialysis to hemodialysis for scarce adherence to fluid restriction. Detection of MRSA on the peritoneal effluent combined with a total white blood cell count of 554 cells/mm3 prompted the diagnosis of satellite MRSA peritonitis. Antibiotic treatment with daptomycin and simultaneous CVC and peritoneal catheter removal resolved the infectious process. No further metastatic localizations were detected elsewhere. In conclusion, S. aureus can induce metastatic infections far from the site of primary infection. As reported in this case, peritonitis can be secondary to the hematogenous dissemination of S. aureus especially in hospitalized patients having a central line.

The PIRP project (Prevenzione Insufficienza Renale Progressiva): how to integrate hospital and community maintenance treatment for chronic kidney disease.

Chronic kidney disease (CKD) represents a global health burden with great economic impact on healthcare and therefore it requires appropriate interventions by Health Care Systems. The PIRP (Prevenzione Insufficienza Renale Progressiva) project is endorsed and funded by the Emilia-Romagna Regional Health Board and involves all the Nephrology Units of the Emilia-Romagna Region (Italy). The project has a predominantly clinical purpose and is expected to bring about a continuous quality improvement in the treatment of patients with CKD. Its aims are to intercept patients in an early phase of CKD, to delay their illness progression and to prevent cardiovascular complications. An integrated care pathway involving nephrologists, general practitioners (GPs) and other specialists has been created to identify patients to whom ambulatory care targeted on effective, efficient pharmaceutical and dietary treatment as well as on lifestyle modifications is subsequently provided. With the cooperation of GPs, in its 13 years of activity the project identified and followed up more than 25,000 CKD patients, who attended the Nephrology units with more than 100,000 visits. The effects of a closer and joint monitoring of CKD patients by GPs and nephrologists can be quantified by the reduction of the mean annual GFR decline (average annual CKD-EPI change: - 0.34 ml/min), and by the decrease in the overall incidence of patients who annually started dialysis in the Emilia-Romagna Region, that dropped from 218.6 (× million) in 2006 to 197.5 (× million) in 2016, corresponding to about 100 cases.

[Challenges and results of the PIRP project (Prevenzione della Insufficienza Renale Progressiva) of the Emilia-Romagna Region].

The PIRP project was conceived in 2004; with the aim to face the increased prevalence of chronic kidney disease (CKD) associated with the aging and increased survival of the population. The first phase of the project consisted of training primary care physicians to identify people at risk of CKD and to implement intervention strategies that proved to be effective in preventing CKD it or delaying its progression once it is established. In the second phase of the project, dedicated ambulatories were opened in the nephrology units of Emilia-Romagna hospitals to provide an in-depth assessment and personalized care to CKD patients, following them up until renal failure or death or referring them back to general practitioners, according to the study protocol. A web-based registry was implemented to collect demographic and clinical data on PIRP patients. As of 30 June 2018, the registry included 26.211 CKD patients, with a median follow-up of 24.5 months. Over the 14 years of the PIRP the mean age of incident patients increased from 71.0 years to 74.2 years and the mean eGFR increased from 30.56 to 36.52 mL/min/1.73 m ², proving that the project was successful in recruiting older patients with a better renal function. At 5 years, the percentage of patients still active in the project was =45%.The implementation of the project has seen a reduction in the number of patients arriving every year to the dialysis treatment in E-R (about 100 units less from 2006 to 2016). The PIRP cohort is the largest in Italy and in Europe, which makes it ideal for research based on international comparisons and as a model for national registries.

Vascular access scenario in Italy: evolution and comparison by two surveys (1998-2013).

PURPOSE: Dialysis settings have generally improved over the last decades, but the vascular access setting did not see significant advances and experienced a progressive worsening in epidemiology and clinical features. The aim of the study was to describe and compare evolution of vascular access in Italy over time. METHODS: A national survey implemented in Italy last year is presented and compared to a previous survey performed in 1998. Present survey collected data from almost 50% of centers involved in vascular access. RESULTS: The nephrologist participates in the management of vascular access in 97% of centers. Almost 40% of centers declare more than 40% of central venous catheters (CVCs) at first dialysis with maximum value being 60%. Prevalence of CVCs is greater than 20% in chronic prevalent patients in 38.8% of centers. According to the 2013 survey, CVCs account for 51.6% of procedures, while arteriovenous fistulae (AVF) and prostheses represent 42.4% and 6%, respectively. Nephrologists perform 73% of procedures on CVCs.From 1998 to 2013, a sharp increase in CVC prevalence was seen, in both incident and prevalent dialysis patients. This activity, mostly due to CVC management, is almost completely carried by nephrologists. DISCUSSION: The variability in CVC utilization among centers suggests the lack of a shared policy in patients and access coupling. Quantitative criteria should be used to reduce inappropriate strategy in vascular access creation. Since this activity in Italy is organized at a local level without a shared organizational model, we should inquire whether a system managed so well in the past should now be rebuilt on the model of organ transplantation.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology.

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

Treatment of wounds colonized by multidrug resistant organisms in immune-compromised patients: a retrospective case series.

BACKGROUND: Immune-compromised patients incur a high risk of surgical wound dehiscence and colonization by multidrug resistant organisms. Common treatment has been debridement and spontaneous secondary healing.We report on the results obtained in nine such patients whose wounds were treated by debridement, negative pressure dressing and direct closure. METHODS: All immune-compromised patients referred to our Institution between March 1, 2010 and November 30, 2011 for dehiscent abdominal wounds growing multidrug resistant organisms were treated by serial wound debridements and negative pressure dressing. They were primarily closed, despite positive microbiological cultures, when clinical appearance was satisfactory.As a comparison, records from patients treated between March 1, 2008 and February 28, 2010 who, according to our Institution's policy at that time, had been left to heal by secondary intention, were retrieved and examined. RESULTS: Nine patients were treated by direct wound closure, five had been treated previously by secondary intention healing.Overall, ten patients had received liver transplant, 1 kidney transplant, 1 was HIV infected, 1 suffered from multi-organ failure, 1 was undergoing hemodialysis.Wound dehiscence involved skin and subcutaneous layers in all patients, in two the muscular layer was also involved.Mean healing time was significantly shorter in patients treated more recently by primary intention in comparison with historical patients (28 vs 81 days). The only complication observed was a small superficial abscess that developed around a non-absorbable stitch 10 months after closure in a patient treated by primary closure. CONCLUSIONS: According to our results, fast healing can be safely obtained by closure of a clinically healthy wound, despite growth of multidrug resistant organisms, even in immune-compromised patients.

[The Italian Registry of Vascular Access]. / Il registro nazionale degli accessi vascolari.

The Vascular Access Study Group of Italian Society of Nephrology has designed a National Register in order to create an archive that collects the data on vascular accesses more detailed than the mere indication of arteriovenous fistula with native vessels, prosthetic fistula and central venous catheter. The obstacles to such a project are represented by the absence of "uniformity" in the name of the arterovenous fistula, the difficulty in increasing the daily work of dialysis centers with another registry and finally by privacy concerns. In order to standardize the vascular accesses name the Study Group proposal is to eliminate any denomination and adopt a code-descriptive system, indicating the seat of the anastomosis (1/3 distal, middle and proximal forearm, arm or lower limb), the limb (if dominant or non-dominant), the vessels involved, the type of anastomosis and the number of interventions that the pt has undergone including the last one. In this way, uniformity and universality are guaranteed. Every aspect scribed will be a cell of a data base and can used to statistical analysis. The study group has set up a software (Gev@) in order to facilitate data storage. The software is based on a form compiled at the end of each surgical procedure. The form will then be archived in digital format thereby generating automatically the data base. The advantage of this system, is represented by the possibility of turning a routine medical procedure, namely the recording of a surgical procedure, in a data base exportable for the creation of the register. As regards the issue of privacy will be obtained the patient's consent to the processing of data and the register will be stored and managed according to the regulations in terms of privacy. In the coming months, after a time of testing, the software will be available to each italian dialisys center.

[Post-transplant recurrence of glomerulonephritis: a complex clinical case]. / Recidiva di glomerulonefrite post-trapianto: un caso clinico complesso.

Lupus nephritis (LN) seldom recurs in a grafted kidney. By contrast, primary membranoproliferative glomerulonephritis (MPGN), which has been included, along with hemolytic uremic syndrome and age-related maculopathy, among the complement dysregulation diseases, has a high recurrence rate and is considered a contraindication to living-donor kidney transplant because of the poor prognosis. We report the case of a young girl with LN-related chronic renal failure who underwent a living donor transplant from her mother. After four months she had a recurrence that did not match the criteria for LN. Graft biopsies and revision of the clinical course pointed to type II MPGN on the basis of a lack of ARA criteria, persistent isolated low C3 levels, and response to plasma therapy. If confirmed by genetic analysis, the patient might benefit from treatment with the monoclonal antibody against the C5-C9 complex, eculizumab.

Biofilm on artificial surfaces.

Biofilms are microbial communities quite different from planktonic cells and most of common microbiological concepts had to be updated in recent years. The peculiar capacity to resist to disinfectants and antibiotics results in biofilms being a public health problem mainly when modern medical devices are used. All artificial surfaces used in medicine may be prone to biofilm attachment and could therefore represent a cause of acute or chronic infectious diseases. Uremic patients are at higher risk from biofilms as not only traditional causes, such as indwelling catheters, but also hemodialysis apparatuses contribute to bacterial exposure. Chemical or physical disinfections have been demonstrated partially active on sessile microorganisms and biofilm avoidance remains the goal to assure an adequate quality of dialytic treatment.