Peritoneal Dialysis in Italy: the 8th GPDP-SIN Census 2022 - 2nd Part: the Centers.

Objectives. The results are presented of the 8th National Census (Cs-22) of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology relating to the characteristics of the Centers in Italy which used PD in 2022. Materials and methods. The 227 non-pediatric centers which used Peritoneal Dialysis (PD) in 2022 took part. The data requested were sent in aggregate form. For the first time, the resources available and training were investigated as well as home visits. The Centers have been divided into Quartiles according to the number of prevalent PD patients at 31/12/2022. Results. Centers with a smaller PD program (<9 pts) are characterized by 1. smaller overall size - 2. fewer personnel (doctors/nurses) dedicated to PD - 3. greater recourse to external personnel for training - 4. Less incremental prescription and evaluation of peritoneal permeability - 5. higher drop-out to HD in particular for choice/impossibility to continue and for adequacy/catheter-related issues. A lower peritonitis rate was recorded in Centers with a more extensive PD program (≥25 pts). Home visits are carried out regularly by a small minority of Centers. Conclusions. The analysis shows an association between size of Center PD program and available resources, PD modality and outcome.

Role of the Opinions of the Nephrologist and Structural Factors in Dialysis Modality Selection. Results of a Peritoneal Dialysis Study Group Questionnaire.

Background. The use of PD depends on economic, structural and organizational factors. The nephrologist's opinion is that peritoneal dialysis is less used than it shold be. In Italy, PD is not carried out in private Centers, but neither is it in around one third of Public Centers. The aim of this study was to investigate the opinions of nephrologists on PD in Public Centers only, thereby nullifying the influence of the economic factors. Materials and Methods. The investigation was carried out by means of an online questionnaire (Qs) via mail, and during meetings and Congresses in 2006-07. The Qs investigated the characteristics of the Centers, the nephrologists interviewed, and opinions on the various aspects of the choice of Renal Replacement Therapy Renal Replacement Therapy (RRT) (26 questions). Responses were received from 454 nephrologists in 270 public Centers. Among these, 205 centers (370 Qs) report PD (PD-YES), 36 (42 Qs) do not (PD-NO) and 29 (42 Qs) do not use it but send patients selected for PD to other Centers (PD-TRANSF). Results. The PD-NO and PD-TRANSF Centers are significantly smaller, with greater availability of beds. In the PD-YES Centers the presence of a pre-dialysis pathway, early referral and nurses dedicated solely to PD are associated with a higher use of PD. The nephrologists in the PD-NO Centers rate PD more negatively in terms of both clinical and non-clinical factors. The belief that more than 40% of patients can do either PD or HD differs among the nephrologists in the PD-YES (74.3%), PD-TRANSF (45.2%) and PD-NO (28.6%) Centers. Likewise, the belief that PD can be used as a first treatment in more than 30% of cases differs among the nephrologists in PD-YES (49.2%), PD-TRANSF (33.3%) and PD-NO (14.3%) Centers. Conclusions. The use of PD in Public Centers is conditioned by both structural and organizational factors, and by the opinions of nephrologists on the use and effectiveness of the technique.

Precision Medicine in Peritoneal Dialysis: An Expert Opinion on the Application of the Sharesource Platform for the Remote Management of Patients.

The management of end-stage kidney disease (ESKD) has been constantly evolving over the last decade with the development of targeted approaches. In this field, telemedicine and remote monitoring are based on the availability of new cyclers that allow for bidirectional communication (between patient and physician) and for the application of the Sharesource cloud-based platform. These technologies allow patients with ESKD to undergo automated peritoneal dialysis (APD) at home. However, these approaches are not well standardized and largely applied yet. Therefore, this study aimed to elaborate a protocol for the utilization of the Sharesource platform to facilitate the practical management of patients treated with APD. A series of expert meetings were held between September 2022 and January 2023 in Italy. The participants (ten nephrologists and five nurses) from nine Italian public dialysis centers shared their opinions, examined the current scientific literature in the field, and reviewed the key characteristics of the Sharesource system to achieve a common position on this topic. A detailed and practical document containing experts' opinions and suggestions on the use of the Sharesource platform for the management of patients treated with APD was produced. This expert opinion might represent a new useful instrument in clinical practice for managing patients undergoing home-based peritoneal dialysis (PD) through the Sharesource platform, which is valid not only for Italy. These recommendations pave the way to novel patient-centered and personalized therapeutic approaches for ESKD and highlight the advantages of telemedicine and remote monitoring in the management of patients with ESKD undergoing PD and its positive impact on their quality of life.

Peritoneal Dialysis in Italy: the 8th GPDP-SIN census 2022

Objectives. The results are reported here of the 8th National Census (Cs-22) of Peritoneal Dialysis in Italy, carried out in 2022-23 by the Italian Society of Nephrology's Peritoneal Dialysis Project Group and relating to 2022. Methods. The Census was conducted in the 227 non pediatric centers which performed Peritoneal Dialysis (PD) in 2022. The results have been compared with the previous Censuses carried out since 2005. Results. Incidence: in 2022, 1350 patients (CAPD=52.1%) started on PD (1st treatment for ESRD). PD was started incrementally by 35.3% in 136 Centers. The catheter was placed exclusively by a Nephrologist in 17.0% of known cases. Prevalence: there were 4152 (CAPD=43.4%) patients on PD on 31/12/2022, with 21.1% of prevalent patients on assisted PD (family member caregiver: 86.3%). Out: in 2022 the PD drop-out rate (ep/100 pt-yrs) was: 11.7 to HD; 10.1 death, down; 7.5 Tx. The main cause of transfer to HD remains peritonitis (23.5%), although its reduction over the years is confirmed (Cs-05: 37.9%). Peritonitis/EPS: the incidence of peritonitis in 2022 was 0.176 ep/pt-yr (696 episodes). The incidence of new cases of EPS fell in 2021-22 (7 cases). Other results: the number of Centers using 3.86% for the peritoneal equilibration test (PET) (57.7%) increased. PD for heart failure continues to be used in 44 Centers (66 pts). Conclusions. Cs-22 confirms PD's good results in Italy.

[Peritoneal Dialysis in Italy: the 7th GSDP-SIN census 2019].

Objectives: Analysis of the results of the 7th National Census (Cs-19) of Peritoneal Dialysis in Italy, conducted in 2020-21 by the Peritoneal Dialysis Project Group of the Italian Society of Nephrology, for the year 2019. Materials and methods: The data was initially collected using specially designed software, which after entering the data of individual patients allows the aggregate extraction of the necessary information. The difficulties due to the COVID pandemic made it necessary to also use the traditional on-line questionnaire used previously. Of the 237 Centers envisaged, 198 responded, of which 177 with complete data for HD also in 2016. Results: Overall incidence and prevalence (31/12/2019) were respectively 1,363 (CAPD/APD = 741/622) and 3,922 (CAPD/APD = 1,857 / 2,065) patients. The percentage incidence and prevalence (177 Centers) decreased compared to 2016, respectively, from 23.8% to 22.1% and from 17.3% to 16.6%. 31.4% started PD incrementally in 60.3% of the Centers. The catheter is placed by the Nephrologist alone in 19.7%. Assisted PD is used by 24.5% of the prevalent patients, mostly (83.8%) by a family member. In 2019, the exit from PD (ep/100 years-pts: 11.6 in HD; 8.9 death; 6.0 Tx) is decreasing for all causes. The main cause of transfer to HD remains peritonitis (26.8%). The incidence of peritonitis in 2019 dropped further to 0.190 ep/year-pts as well as the incidence of new cases of EPS (0.103 ep/100 years-pts). Conclusions: The Cs-19 confirms the good results of the DP in Italy.

Serum fetuin a in hemodialysis: a link between derangement of calcium-phosphorus homeostasis and progression of atherosclerosis?

BACKGROUND: Fetuin A, a circulating inhibitor of ectopic calcification, is downregulated in hemodialysis and has been shown to predict cardiovascular mortality in this setting. The association of altered calcium-phosphorus with serum fetuin A levels is still a matter of debate. Although carotid intima-media thickness (cIMT) is a strong predictor of major cardiovascular events, its association with serum fetuin A levels is poorly defined. STUDY DESIGN: Cohort study. PARTICIPANTS & SETTINGS: 174 uremic patients on long-term hemodialysis therapy enrolled in 4 university hospitals. PREDICTORS: Serum fetuin A levels at the beginning of the study (T0) and after 12 months (T12). OUTCOMES: Progression of atherosclerosis assessed by means of cIMT measurements at 24 months (T24); cardiovascular morbidity and mortality at 36 months. RESULTS: Serum fetuin A concentrations at T0 and T12 were 282.3 +/- 79.4 and 290.0 +/- 92.2 microg/mL, respectively. Mean T0 and T24 cIMT values were 1.02 +/- 0.2 and 1.06 +/- 0.2 mm, respectively (P < 0.001). Fatal and nonfatal cardiovascular disease occurred in 36 and 86 patients by 36 months, respectively. In multivariate logistic regression, higher calcium-phosphorus product was associated with lower serum fetuin A level (odds ratio, 0.96; 95% confidence interval [CI], 0.93 to 1.00; P = 0.02). Multiple regression analysis showed that T0 serum fetuin A level was associated with T24 cIMT (P = 0.01) after adjustments for age, cholesterol level, high-sensitivity C-reactive protein level, previous cardiovascular events, and T0 cIMT. In a multivariate Cox regression analysis, cardiovascular mortality was independently associated with a 1-tertile lower T0 serum fetuin A level, and a 1-tertile higher T0 cIMT value was independently associated with greater cardiovascular mortality (hazard ratio, 0.45; 95% CI, 0.15 to 0.65; P = 0.007 and hazard ratio, 10.00; 95% CI, 3.16 to 31.73; P < 0.001, respectively) after adjustment for age and previous cardiovascular events. LIMITATION: Length of follow-up. CONCLUSION: Calcium-phosphorus product in hemodialysis patients inversely correlated with serum fetuin A level, which, in turn, was associated inversely with progression of atherosclerotic lesions and cardiovascular mortality in this study population.

Dialysis-related systemic microinflammation is associated with specific genomic patterns.

BACKGROUND: Although several reports have focused on the clinical importance of the systemic microinflammatory state in the uraemic population, the relationship between the activation of a specific transcriptome and the development of this condition is still not completely defined. METHODS: Thirty haemodialysis (HD), 30 peritoneal dialysis (PD) and 30 chronic kidney disease (CKD) patients were enrolled in our study. For all patients, serum C-reactive protein (CRP) and ferritin levels were determined. In addition, the expression level of 234 inflammatory responses and oxidative stress pathway genes was measured, using oligonucleotide microarray chips (HG-U133A, Affymetrix), in peripheral blood mononuclear cells of 24 randomly selected patients (8 HD, 8 PD and 8 CKD). RESULTS: HD patients demonstrated higher CRP and ferritin levels compared to PD and CKD patients (P < 0.001). Statistical analysis identified 10 genes able to discriminate CKD from HD and PD patients (FDR = 5%, P < 0.001) and significantly correlated to CRP levels. All together, these genes were able to predict inflammation with an accuracy of 87% (P < 0.001). Among the selected genes there were those encoding for key regulators of inflammation and oxidative stress (e.g. RELA, GSS). Interestingly, only three inflammatory genes (MIF, IL8RB and CXCL12) were still significantly associated with inflammation when included in a multivariate analysis. RT-PCR for RELA, MIF, CXCL12 and western blots for IL8RB and GSS, using 66 patients, validated the microarray results. CONCLUSIONS: This study may help to better understand the physiopathology of the systemic inflammatory state in CKD and dialysis patients and to identify new target genes potentially useful for future bio-molecular studies and therapeutic approaches.