[Dialysis and quality of life: identifying and managing critical aspects]. / Terapia dialitica e qualitá di vita: individuare le aree di criticitá per orientare alla metodica più idonea.

Living with a chronic disease is for the patient a ''disease experience'' that also affects the psychosocial sphere and has a negative impact on perceived quality of life. To estimate the effect of dialysis on the perceived quality of life and to identify by means of a specific questionnaire the aspects that are compromised most. From our results it emerged that the examined patients had a sufficiently good total perception of quality of life, even though about 30% of the patients reported critical aspects related to daily life and, in some age groups, also related to dialysis method. This study confirms the importance of developing educational and supportive predialysis programs in order to identify and reduce the critical aspects.

Gastric pH, sevelamer hydrochloride and omeprazole.

AIMS: Sevelamer hydrochloride is a polymer containing multiple amines (40% amine hydrochloride) separated by one carbon from the polymer backbone, and it is not absorbed by the intestine. These amines are partially protonated and interact with phosphate molecules through ionic and hydrogen bonding, therefore reducing phosphate absorption and lowering serum phosphate concentration. Alterations of gastric pH, in particular excessive alkalinization, could interfere with sevelamer phosphate binding capacity. CASE HISTORY: A 30-year-old dialysis patient affected by secondary hyperparathyroidism started sevelamer treatment, 4.8 g/day, with a basal serum phosphate of 6.9 mg/dl. The patient was also treated with omeprazole (20 mg/day) because of chronic gastritis. Phosphate levels normalized (4.2 mg/dl), but after four months of follow-up serum phosphate unexpectedly increased to 7.2 mg/dl. We found out that in the same period she had autonomously increased the dosage of omeprazole to 80 mg/day, due to worsening of dyspepsia. Gastric pH measurement showed a median level of 4.1, rather than the normal values of 1 - 2, indicating excessive pharmacological alkalinization. When omeprazole was reduced to the correct dose of 20 mg/day, we observed a rapid decrease of phosphate levels. CONCLUSION: This case report highlights the influence of gastric pH on sevelamer phosphate binding capacity. The high dose of omeprazole and the consequent excessive increase in gastric pH was probably responsible for a decreased phosphate binding capacity of sevelamer. When patients taking appropriate doses of sevelamer do not respond to treatment, a potential interaction with drugs determining an increase of gastric pH should be considered.