Relacion entre las cantidades de cobre y zinc administradas a pacientes graves con nutrición parenteral total y los niveles de cobre y zinc en plasma y eritrocitos / Relationship between the amount of copper and zinc given to critically ill patients on total parenteral nutrition and plasma and erythrocyte copper and zinc levels

Objetivos: Evitar tanto las complicaciones por deficiencia de zinc y de cobre como los efectos adversos del exceso en pacientes graves que requirieron nutrición parenteral, estudiando la relación entre las cantidades de zinc y de cobre administradas en las mezclas de nutrición parenteral y los cambios en algunos indicadores bioquímicos de los pacientes, con respecto a zinc y cobre. Pacientes y metodología: 29 pacientes graves, adultos, con pancreatitis o sometidos a cirugía mayor abdominal. Se determinó, al inicio y al final del tratamiento (5-21 días): cobre y zinc en las mezclas de nutrición parenteral administradas y en eritrocitos (GR), zinc en plasma y cobre en suero (Espectrometría de Absorción Atómica). Resultados (promedio ± DE, rangos: entre paréntesis): los valores de zinc y cobre en las mezclas de nutrición parenteral fueron (μg/mL): zinc: 4,2 ± 1,7 (1,8 a 9,3); cobre: 0,94 ± 0,66 (0,1 a 3,1); zinc plasmático (μg/dl): inicio 80 ± 45 (29-205); final: 122 ± 56 (37-229); zinc eritrocitario (μg/dl): inicio: 2.300 ± 1.070 (790-5280); final: 2.160± 920 (790-4.440); cobre sérico (μg/dl): inicio: 124 ± 35 (62-211); final: 128 ± 41 (60-238); cobre eritrocitario (μg/dl): inicio: 72 ± 39 (4-183); final: 70 ± 41 (9-156). Los cambios porcentuales de los niveles de zinc eritrocitario correlacionaron con el zinc (mg/d) en las mezclas de nutrición parenteral (r = 0,38). Las variaciones de cobre sérico y eritrocitario correlacionaron positivamente con los valores de cobre administrado (mg/d) en las mezclas de nutrición parenteral (r = 0,31 y 0,26, respectivamente). Conclusiones: Estos resultados evidenciaron que: 1) las determinaciones de zinc eritrocitario, cobre sérico o eritrocitario serían de utilidad para controlar los niveles de zinc y de cobre administrados en las mezclas de nutrición parenteral a los pacientes graves; 2) las dosis de zinc deberían ser menores a 8,1 mg/d, y 3) no sería aconsejable administrar dosis de cobre superiores a 1,2 mg/d (AU)

Objectives: Complications resulting from zinc and copper deficiency, or adverse effects from excessive zinc and copper intake should be avoided during total parenteral nutrition (TPN). This study was conducted on critically ill patients requiring TPN to determine the relationship between the zinc and copper levels of the TPN mixtures, patients' clinical progression, and changes in plasma levels of zinc, serum levels of copper, and erythrocyte levels of zinc and copper. Patients and methods: 29 adult critically ill patients following pancreatitis or after a major abdominal surgery were studied. Zinc and copper levels in TPN, plasmatic zinc levels, copper serum levels and erythrocyte levels of zinc and copper were determined at the onset and at the end of the treatment (5-21 days) (using Atomic Absorption Spectrometry). Results: The mean ± standard deviation (and ranges in parenthesis) of zinc and copper levels in TPN were (μg/mL): zinc: 4.2 ± 1.7 (1.8 a 9.3); copper: 0.94 ± 0.66 (0.1 a 3.1). Biochemical parameters at the onset and at the end of the treatment were, respectively: (μg/mL): plasmatic zinc: 80 ± 45 (29-205) and 122 ± 56 (37-229); erythrocyte zinc: 2,300 ± 1,070 (790-5,280) and 2,160 ± 920 (790-4,440); serum copper (μg/dL): 124 ± 35 (62-211) and 128 ± 41 (60- 238); erythrocyte copper (μg/dl): 72 ± 39 (4-183) and 70 ± 41 (9-156). Plasmatic and erythrocyte zinc levels did not correlated neither at the onset nor at the end of the treatment. Changes in erythrocyte zinc levels correlated with daily administered zinc (mg/d) in the parenteral nutrition (r = 0.38). Serum copper and erythrocyte copper showed significant correlation at the onset (p = 0.0005) and at the end of treatment (p = 0.008). Changes of serum or erythrocyte copper levels showed a significant correlation with daily administered copper (r = 0.31 and 0.26, respectively). Conclusions: These results show that: 1) determination of erythrocyte zinc and copper levels in these critically ill patients would help to control zinc and copper administration levels in TPN and avoid adverse effects; 2) TPN Zn levels should be less than 8.1 mg/d, and 3) TPN Cu levels higher than 1.2 mg/d would not be recommended (AU)

[Relationship between the amount of copper and zinc given to critically ill patients on total parenteral nutrition and plasma and erythrocyte copper and zinc levels]. / Relación entre las cantidades de cobre y zinc administradas a pacientes graves con nutrición parenteral total y los niveles de cobre y zinc en plasma y eritrocitos.

OBJECTIVES: Complications resulting from zinc and copper deficiency, or adverse effects from excessive zinc and copper intake should be avoided during total parenteral nutrition (TPN). This study was conducted on critically ill patients requiring TPN to determine the relationship between the zinc and copper levels of the TPN mixtures, patients' clinical progression, and changes in plasma levels of zinc, serum levels of copper, and erythrocyte levels of zinc and copper. PATIENTS AND METHODS: 29 adult critically ill patients following pancreatitis or after a major abdominal surgery were studied. Zinc and copper levels in TPN, plasmatic zinc levels, copper serum levels and erythrocyte levels of zinc and copper were determined at the onset and at the end of the treatment (5-21 days) (using Atomic Absorption Spectrometry). RESULTS: The mean+/-standard deviation (and ranges in parenthesis) of zinc and copper levels in TPN were (microg/mL): zinc: 4.2+/-1.7 (1.8 a 9.3); copper: 0.94+/-0.66 (0.1 a 3.1). Biochemical parameters at the onset and at the end of the treatment were, respectively: (microg/mL): plasmatic zinc: 80+/-45 (29-205) and 122+/-56 (37-229); erythrocyte zinc: 2,300+/-1,070 (790-5,280) and 2,160+/-920 (790-4,440); serum copper (microg/dL): 124+/-35 (62-211) and 128+/-41 (60- 238); erythrocyte copper (microg/dl): 72+/-39 (4-183) and 70+/-41 (9-156). Plasmatic and erythrocyte zinc levels did not correlated neither at the onset nor at the end of the treatment. Changes in erythrocyte zinc levels correlated with daily administered zinc (mg/d) in the parenteral nutrition (r=0.38). Serum copper and erythrocyte copper showed significant correlation at the onset (p=0.0005) and at the end of treatment (p=0.008). Changes of serum or erythrocyte copper levels showed a significant correlation with daily administered copper (r=0.31 and 0.26, respectively). CONCLUSIONS: These results show that: 1) determination of erythrocyte zinc and copper levels in these critically ill patients would help to control zinc and copper administration levels in TPN and avoid adverse effects; 2) TPN Zn levels should be less than 8.1 mg/d, and 3) TPN Cu levels higher than 1.2 mg/d would not be recommended.

[1966: an automatic peritoneal dialysis machine. A personal experience]. / 1966: un'apparecchiatura di dialisi peritoneale automatica. Un'esperienza personale.

In 1966 a self-made peritoneal dialysis machine according to Boen's model was built at the Nephrology Unit of the University of Turin (Italy) to facilitate the conduction of "rapid-exchange" peritoneal dialysis. Three timers controlled the dialysate inflow, dwell and outflow phases. Inflow and outflow times were reduced by means of wide dialysate lines and negative pressure in the drainage reservoir. A mechanical recorder registered the outflow curves. With rapid-exchange peritoneal dialysis, urea clearance increased from 18 to 34 mL/min, thereby improving the treatment of both acute and chronic renal failure patients.

[2004 census of the Italian nephrology and dialysis units]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani.

The Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyze structural and human resources, organizational aspects, activities and epidemiological data. An online 158-item questionnaire for the year 2004 was used. Three hundred sixty-three public renal units, 303 satellite dialysis centers and 295 private dialysis centers were identified, resulting in a total of 961 dialysis centers (16.4 per million population, pmp). The inpatient renal beds were 2,742 (47 pmp). Renal and dialysis activity was performed by 3,728 physicians (64 pmp), of whom 2,964 (80%) were nephrologists. There was no permanent medical assistance in 41% of the satellite dialysis centers. Renal admissions (1,800 pmp) and renal biopsies (99 pmp) were done. The management of the acute renal failure was one of the most relevant activities in the public renal units (13,456 cases, 230 pmp). In 2004 9,858 new cases of end-stage renal disease (169 pmp) were diagnosed. On December 31st 2004, 43,293 patients (741 pmp) were on renal replacement therapy, of whom 89.7% on hemodialysis and 10.3% on peritoneal dialysis. Renal transplant recipients were 16,765 (287 pmp). The benchmark data derived from this census show interesting comparisons between centers, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

[Withdrawing or discontinuing chronic dialysis in adult patients]. / Non avvio o sospensione del trattamento dialitico cronico nell'adulto: considerazioni cliniche, relazionali, bioetiche e legislative.

Dialysis treatment leads chronic uremic patients to a prolonged survival; incidence and prevalence of dialysis patients are increasing, the population is getting older and many comorbidities coexist, such as diabetes, heart diseases, vasculopathies, neoplasia. The question often arises of whether to start or continue dialysis treatment in compromised patients. Withdrawing and/or discontinuing dialysis represents a therapeutic option with different ratios among countries, due to various cultural, religious, legal and social aspects. Italy shows a low prevalence, but a future increase is likely to appear. The crucial issue is the doctor-patient relationship: thanks to recent legal regulations, the patient has started to play an active role in the therapeutic decision making, by signing or not the informed consent regarding the therapeutic options suggested. In the Piemonte Region we evaluated the behavior of the nephrology operating units, through a consultant- and head nurses team-oriented survey. Most interviewees assert that starting a dialysis treatment is not always mandatory for every patient. The choice of per-forming dialysis should always be based on patient informed consent and in agreement with the physician in charge, the family and the patient himself. It is fundamental to choose to discontinue dialysis consistently with patients' prognosis and their concept of quality of life. It is mostly believed to be a legal and deontological duty to continue dialysis treatment, should any clear patient's will declaration lack.

[Census 2004 of the Italian renal and dialysis units. Basilicata - Calabria - Puglia]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Basilicata - Calabria - Puglia.

The Italian Society of Nephrology (SIN) sponsored in 2004 a National Census of the Italian renal and dialysis units. This paper presents the main structural, technical, organizational features, as well as the human resources and the activities of three South-East regions of Italy: Basilicata (B), Calabria (C), and Puglia (P). EPIDEMIOLOGY: incidence of dialysis patients was 149 per million population (pmp) in B, 134 pmp in C and 172 pmp in P; prevalence of dialysis patients 729, 694 and 886 pmp, respectively; prevalence of transplanted patients 188 in B, 264 in C and 249 pmp in P; gross mortality rate of dialysis patients was 12.7% (B), 12.2% (C) and 10.8% (P). TYPE OF VASCULAR ACCESS IN PREVALENT DIALYSIS PATIENTS: arteriovenous fistula: 83.9% (B), 87.7% (C) and 86.5% (P); central venous catheter: 14.2% (B), 8.4% (C) and 11.2% (P); vascular graft 1.9% (B), 3.9% (C) and 2.3% (P). STRUCTURAL RESOURCES: nephrological beds 37, 34 and 88 pmp, respectively; dialysis stations 265, 209 and 207 pmp. PERSONNEL RESOURCES: renal physicians 45 (B), 67 (C) and 64(P) pmp; renal nurses 189, 190 and 207 pmp; each nephrologist cares for 16 (B), 10 (C) and 14 (P) dialysis patients, whereas each renal nurse takes care of 3.8 (B), 3.7 (C) and 4.3 (P) dialysis patients. ACTIVITY: hospitalizations 1378, 1834 and 3439 pmp, respectively; renal biopsies 40 (B), 64 (C) and 107 (P) pmp. The main goal of this project was to create a reference for benchmarking studies. Therefore, data from the Puglia region were compared to data from other regions with similar population size (such as Piemonte and Emilia-Romagna). Moreover, a Census may became a useful qualitative tool for renal registries: this report compares data from the Census with data collected by the dialysis and transplantation registry of the Puglia region. Generally speaking, prevalence for Basilicata and Calabria is close to the Italian one, whereas incidence is inferior; things are opposite in Puglia. Furthermore, compared to Basilicata, Calabria and Italy on average, the Puglia region shows a significant higher number of in-patient beds and a lower DRG weight. Compared to Piemonte, Emilia Romagna and Italy on average, all the three South-East regions do not show differences in number/pmp of dialysis centres. More physicians (nephrologists = 80%) are reported to be active in Puglia and Calabria, compared to Piemonte and Emilia Romagna. Nurses in Puglia look after a greater number of dialysis patients than in Calabria and Basilicata. The number of renal biopsies/ pmp is similar to the Italian mean only in Puglia; it is inferior in the other two regions. These data highlight many differences among these three South-East regions, as well as among Piemonte, Emilia Romagna and Puglia. A relevant inequality in health care structures and resources has been found and discussed.

[Census 2004 of the Italian nephrology and dialysis units. Campania, Sicilia and Sardegna]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Campania - Sicilia - Sardegna.

This paper completes the 2004 national survey of Renal and Dialysis Units organised by the Italian Society of Nephrology (SIN), and presents data from the last three Italian Regions, Campania, Sicilia and Sardegna. The major purpose of this initiative was to obtain a benchmark reference on national and regional basis. Main findings in the 3 Regions, respectively: A) STRUCTURAL RESOURCES: Renal Units = 28, 30, 19; Private Dialysis Units = 126, 95, 4; total Renal and Dialysis Units 27, 26, 21 pmp (per million population); % of private facilities = 81, 74, 12%; hospitalization beds = 35, 40, 32 pmp; dialysis stations = 337, 356, 265 pmp. B) PERSONNEL RESOURCES: physicians = 88, 75, 67 pmp; dialysis nurses = 162, 136, 247 pmp; each physician treats 10, 12, 12 dialysis patients and each dialysis nurse treats 4.7, 4.0, 3.3 dialysis patients. C). ACTIVITY: hospitalizations = 1334, 1911, 1851 pmp; renal biopsies = 50, 66, 100 pmp. D). EPIDEMIOLOGY: prevalence of dialysis patients = 842, 915, 822 pmp; prevalence of transplanted patients = 269, 212, 327 pmp; incidence of dialysis patients = 187, 199, 150 pmp; gross mortality rate of dialysis patients = 12.9%, 12.1%, 12.5%; distribution of vascular accesses in prevalent dialysis patients: arteriovenous fistulas = 93%, 84%, 77%; central venous catheters = 6%, 12%, 15%,; vascular grafts = 1%, 3%, 8%. Compared to other Regions, Campania and Sicilia have an abnormal high rate of private Dialysis Units, resulting in difficulties in optimizing structural and economic resources. Furthermore, the independence of some of these structures from a Renal Unit interferes with an adequate treatment of dialysis patients.

[Census 2004 of the Italian Renal and Dialysis Units. Emilia-Romagna, Toscana]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Emilia-Romagna - Toscana.

The 2004 SIN census of the Italian nephrology and dialysis centres showed many interesting data about the epidemiology and the organization in the Regions of Emilia-Romagna (ER) and Tuscany (T). A) Epidemiology: incidence of dialysis patients 169 pmp (patients per million population) in ER, 147 ppm in T; prevalence of dialysis patients 639 pmp and 665 pmp, respectively; prevalence of transplanted patients 325 ppm in ER and 233 pmp in T; gross mortality of dialysis patients 16.3% and 13.4%, respectively; B) Type of vascular access in prevalently dialysis patients: arteriovenous fistula 83% and 78%; central venous catheter 13% and 12%; vascular graft 5% and 9%. C) Structural resources: nephrology beds 44 mp (per million population) and 50 mp; dialysis places 157 and 146 mp. D) Personnel resources : renal physicians 29 and 41 mp; renal nurses 171 and 202 mp ; each renal physician cares for 22 and 16 dialysis patients, and each renal nurse takes care of 3.7 and 3.3 dialysis patients. E) Activity: hospital admissions 1572, 1769 pmp; renal biopsies 115 and 166 pmp.

[Census of the Italian Nephrology and Dialysis Units. Comparison between Lombardy and Piedmont]. / Censimento 2004 Centri di Nefrologia e Dialisi. Confronto tra Piemonte e Lombardia.

The Italian Society of Nephrology promoted a national survey to obtain detailed information from all the Renal and/or Dialysis Units through an on-line questionnaire concerning structural, technological and human resources, as well as organisation characteristics and activities. The purpose of this initiative was to obtain regional reference benchmarks for each Nephrology Unit. In this paper we compare two northwestern Italian Regions: Lombardy and Piedmont. As far as epidemiology is concerned, the prevalence of dialysis patients is quite similar in the two Regions: for haemodialysis 616 pmp (patients per million population) in Lombardy and 595 in Piedmont, for peritoneal dialysis 104 pmp vs. 114 pmp, while the incidence of dialysis patients is 169 vs. 166 pmp. The gross mortality for dialysis patients is 12.4% vs. 13.7% and 0.9% vs. 2.0% in transplanted patients. The distribution of vascular access is also quite similar in the two Regions: prevalent arteriovenous fistula 83% vs. 74%, central venous catheter 11% vs. 18%, vascular grafts 7% vs. 8%. Structural resources: the hospital beds (49 pmp in the two Regions) and the dialysis places (161 vs. 166 pmp) do not differ between the two Regions. Personnel resources: physicians 37 pmp in Lombardy and 44 pmp in Piedmont, renal nurses 167 pmp vs. 186, respectively. Activity: hospital admission 1722 pmp vs. 1507 pmp, renal biopsies 131 pmp vs. 109 pmp. Although the two regions examined are numerically different, both have a high standard of quality, making Italy a model of nephrology organisation. This initiative to take a census of the Italian Nephrology and Dialysis Units provides an interesting tool to describe the present status of the operational structures, to identify precise benchmarking values, at both the regional and national level, and to act as a prelude for further rationalization and growth of the nephrology network in Italy.

[Census 2004 of the Italian Renal and Dialysis Units. Veneto, Friuli Venezia Giulia and Trentino Alto Adige]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Veneto - Friuli Venezia Giulia - Trentino Alto Adige.

The Italian Society of Nephrology (SIN) promoted a national survey of the Renal and Dialysis Units using an online questionnaire on some aspects of structural, technological and personnel resources, as well as organisation and activity. The major aim of this initiative was to obtain a reference benchmark on a national and regional basis. In this paper the data of the northestern regions of Italy (Veneto, Friuli-Venezia Giulia and Trentino-Alto Adige) are reported and compared with the recently published results of the northwestern regions (Piedmont, Liguria and Valle d'Aosta). From an epidemiologic point of view, the prevalence of dialysis patients was 534 pmp (per million population) in Veneto, 667 pmp in Friuli VG and 545 in Trentino AA, the prevalence of transplanted patients was 265, 294 and 404 pmp, respectively; the incidence of dialysis patients was 137, 182 and 130 pmp; gross mortality was 12.5, 14.3 and 16.5%; the distribution of vascular accesse in prevalently dialysis patients was: arteriovenous fistulas = 84.5, 70.4 and 80.9%, central venous catheters = 10.6, 20.0 and 10.2%, vascular graft = 4.9, 9.6 and 8.8%. Regarding structural resources, the distribution of hospital bed numbers was 38, 42 and 43 pmp; dialysis places were 137, 181 and 172 pmp. Human resources were given by renal physicians = 28.3, 38.2 and 23.6 pmp and renal nurses = 138, 200 and 172 pmp; each renal physician took care of 19, 17 and 23 dialysis patients and each renal nurse cared for 3.9, 3.3 and 3.2 dialysis patients. Activity data showed 1436, 1328 and 974 pmp hospital admissions, kidney biopsies were 106, 114 and 31 pmp. Overall, the Italian Northeast shows a significantly lower prevalence and incidence of end-stage renal disease patients than the Northwest; on the contrary, the incidence of patients with acute renal failure is significantly higher. In the Italian Northeast a significantly lower number of hospital beds devoted to renal patients is observed, while dialysis places are more frequent. In the Northeast fewer renal physicians are present than in the Northwest, whereas renal nurses are equivalent if related to the number of dialysis patients. Activity indexes, intended as amount of hospital admissions and renal biopsies standardised per population, are less significant in the Northeast. The results of the survey in Veneto, Friuli VG and Trentino AA show some discrepancies in the treatment of chronic kidney disease between the three regions and even more among different areas of Italy. Despite similar health care models, a relevant inequality in health care resources is evident.

[Census 2004 of the Italian renal and dialysis units--Abruzzo-Lazio-Marche-Molise-Umbria]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Abruzzo-Lazio-Marche-Molise-Umbria.

The Italian Society of Nephrology (SIN) promoted a national survey in order to collect detailed information from all Italian renal and dialysis units. This is the second paper, following the first one which focused on three northwestern regions, aim-ing to present the results of the survey. In this paper, data from the central regions (Abruzzo, Lazio, Marche, Molise and Umbria) are reported. The most relevant findings in the five regions were: A) epidemiology--prevalence of dialysis patients = 742, 781, 731, 814, 768 per million population (pmp); prevalence of transplanted patients = 162, 153, 296, 134, 304 pmp; incidence of dialysis patients = 175, 179, 184, 143, 162; gross mortality of dialysis patients = 12.3, 11.8, 15.9, 13.4, 14.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 90, 87, 82, 94, 80%, central venous catheter = 7, 10, 15, 4, 17%; vascular graft = 3, 3 ,3, 2, 3%. B) Structural resources--number of hospital beds = 52, 43, 39, 62, 44; dialysis places = 205, 260, 203, 301, 226. C) Personal resources--renal physicians = 50, 78, 47, 53, 47 pmp; renal nurses = 162, 172, 180, 224, 245 pmp; each renal physician takes care of 15, 10, 16, 15, 17 dialysis patients and each renal nurse cares of 4.6, 4.6, 4.1, 3.6, 3.1 dialysis patients. D) Activity--admission to hospital= 2334, 1689, 2652, 1255, 1377 pmp; renal biopsies = 59, 84, 97, 19, 80 pmp. Despite the differences we find among the regions, most indexes are similar and show a satisfactory level of renal care provided in the central regions examined.

[Census 2004 of the Italian Renal and Dialysis Units--Piemonte, Liguria and Valle d'Aosta]. / Censimento 2004 dei Centri di Nefrologia e Dialisi italiani. Piemonte--Liguria--Valle d'Aosta.

The Italian Society of Nephrology (SIN) promoted a national survey in order to obtain detailed information from all Renal and/or Dialysis Units using the on-line questionnaire (158 items) regarding structural and technological resources, medical workforce organisation and activity features. The purposes of this initiative were to obtain regional benchmarks as references for renal units and to describe the current Italian renal network in order to plan further interventions for the next 5 years. In this paper data of the first three Italian Regions (Piemonte, Liguria and Valle d'Aosta) which completed the survey (100% of the units) are reported. Main findings in the 3 Regions. A) Epidemiology: prevalence of dialysis patients = 709, 720, 787 pmp (per million population); prevalence of transplanted patients = 325, 387, 279 pmp; incidence of dialysis patients = 166, 191, 156 pmp; gross mortality of dialysis patients = 13.7, 15.0, 13.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 74, 83, 76%, central venous catheter = 18, 12, 15%, vascular graft = 8, 5, 9%. B) Structural resources: hospital's number of beds = 49, 72, 49 pmp, dialysis places = 166, 158, 164 pmp. C) Personnel resources: renal physicians = 44, 47, 41 pmp, renal nurses = 186, 194, 205 pmp; each renal physician takes care of 16, 15, 19 dialysis patients and each renal nurse cares for 3.8, 3.7, 3.8 dialysis patients. D) Activity: admission to hospital = 1507, 2392, 1606 pmp, renal biopsies = 109, 133, 57 pmp. Despite discrepancies in population density in the three Regions, most indexes are surprisingly similar and show the satisfactory level of renal care attained in the Northwestern Italian area. Further improvements in health care management can be predicted as a consequence of a direct comparison between needs and results in the various Regions of the Country.

[SIN survey on quality control of dialysis water in Italy]. / Indagine SIN sui controlli delle acque di dialisi in Italia.

BACKGROUND: The importance of high quality water for dialysis is well established. This study aimed to obtain a picture of the Italian situation to develop national guidelines. METHODS: Questionnaire analysis was used to assess water quality control protocols and types of chemical and microbiological parameters monitored. Regions with responses from at least half the units were considered for the study. RESULTS: Eighteen out of 20 regions fulfilled the inclusion criteria; 297/469 dialysis units answered the questionnaire (5208 dialysis beds, 18213 patients). Eighty-one percent of Italian units follow a regular water quality control program. The reverse osmosis outlet is the sampling point used most for assessing chemical and microbiological parameters. The most common frequency in monitoring is < or =6 months. Fifteen chemical items, suggested by the Italian Farmacopea Ufficiale (FU), are periodically controlled by at least half the units. Aluminum is measured in about 70% of units, chloramines and volatile halogenated hydrocarbons, respectively, in 42 and 30% of units. According to the FU, bacterial counts at 22 degrees C (84%) and endotoxin determinations (60%) are the most common microbiological analyzes. CONCLUSIONS: The survey demonstrated protocol differences among the units, confirming the need for Italian guidelines to ameliorate and standardize dialysis water monitoring. More than half the units are following the FU, but we cannot rule out less strict monitoring only in non-participating units.

[Guidelines on water and solutions for dialysis. Italian Society of Nephrology]. / Linee Guida su acque e soluzioni per dialisi.

The National Society of Nephrology has promoted the development of specific Italian Guidelines for dialysis fluids. Two previous national inquiries showed a wide variety in the type and frequency of both microbiological and chemical controls concerning dialysis water, reinforcing the need for specific standards and recommendations. An optimal water treatment system should include tap water pre-treatment and a double reverse osmosis process. Every component of the system, including the delivery of the treated water to the dialysis machines, should prevent microbiological contamination of the fluid. Regular chemical and microbiological tests and regular disinfection of the system are necessary. 1. Chemical quality (Table: see text). Treated tap water used to prepare dialysis fluid should be within European Pharmacopoeia limits at the water treatment system inlet and at the reverse osmosis outlet. In addition dialysate, concentrate and infusion fluids must comply with specific Pharmacopoeia limits. The physician in charge of the dialysis unit is advised to institute a multidisciplinary team to evaluate the requirement for added chemical controls in the presence of local hazards. 2. Microbiological quality (Table: see text). High microbiological purity of dialysis fluid--regularly verified--is a fundamental prerequisite for dialysis quality and every dialysis unit should aim as a matter of course to obtain "ultra-pure" dialysate (microbial count <0.1 UFC/mL, endotoxins <0.03 U/mL). On-line dialysate ultrafiltration and regular disinfection of dialysis machines greatly enhance microbiological purity. On-line dialysate reinfusion requires specific devices used according to corresponding instructions and to more frequent microbiological tests. Dialysis fluids for home dialysis should comply with the same chemical and bacteriological quality. The appendix reports the water treatment system's technical characteristics, sampling and analytical methods, monitoring time-tables, as well as the origin and effects of the main toxic substances. Suggestions and questions concerning these guidelines are welcome to nefrologia@sin-italy.org.

[Plasmatic and erythrocytic zinc and copper levels in critically ill patients on parenteral nutrition and their relationship with formulas content: preliminary study]. / Niveles plasmáticos y eritrocitarios de zinc y cobre en pacientes críticos con nutrición parenteral y su relación con el contenido de las fórmulas: estudio preliminar.

OBJECTIVES: To study in severe patients that required parenteral nutrition the relationship between Zn and Cu amounts present in formulas, the clinical course and changes in some biochemical parameters (plasmatic and erythrocytic Zn and Cu levels) during the parenteral nutrition therapy. PATIENTS AND METHODOLOGY: Five adult severe patients were studied, submitted to major abdominal surgery, and that required parenteral nutrition. Determinations were done for: 1) Zinc and copper in parenteral formulas; 2) in patients, at the beginning (T0) and at the end (Tf) of treatment, in erythrocytes: zinc (Zn-E) and cupper (Cu-E); in plasma, zinc (Zn-Pl) and in serum, cupper (Cu-S). Zinc and cupper were determined by means of atomic absorbance spectrometry. RESULTS: mean +/- standard deviation values and ranges (between brackets) were: parenteral formulas (microg/g): zinc: 0.6 +/- 1.1 (2.2 - 7.0); Cupper: 2.4 +/- 0.7 (0.5-3.7). Biochemical parameters: at T0 (n = 5): Zn-E (microg/mL): 21.6 +/- 10.0 (13.6-36.1); Zn-Pl (microg/dL): 88 +/- 72 (29-205); Cu-E (microg/dL): 113 +/- 22 (60-102); Cu-E (microg/dL): 139 +/- 29 (106 +/- 156); Cu-S (microg/dL): 172 +/- 20 (158-195). Individual values compared to reference ones (normal individual from Buenos Aires with adequate nutrition) indicated that the three patients with favorable course normalized Zn-Pl and Zn-E levels. However, Cu-S increased in the three cases and Cu-E in two of them. CONCLUSIONS: These results make clear that in the studied patients Zinc levels in parenteral formulas would be adequate to prevent deficiency while Copper levels could be too high.

[Italian Registry of Dialysis and Transplantation: 1996-2001 experience]. / Registro Italiano Dialisi e Trapianto. Esperienza 1996-2001.

The Italian Registry of Dialysis and Transplantation (RIDT) was born in 1996 under the aegis of the Italian Society of Nephrology, and it is organized as a federation of regional registries. This study aimed to completely revise the epidemiological data collected during the first 5 yrs (1996-2001) of RIDT activity to evaluate the trends of the main epidemiological features. During this period, regional registries were not always able to assure complete and exhaustive information according to RIDT requirements, owing to different levels of organization and functioning. To avoid any possible error in data analysis, information inadequately assessed was refused. The incidence of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT) in Italy has increased from 114 pmp in 1996 to 139 pmp in 2001, that means an increase of 3.5%/yr, corresponding to 5718 patients during 1996 and 8000 patients during 2001. Primary renal diseases (according to the EDTA) in incident ESRD patients are vascular and diabetic nephropathy. Main dialysis modality in incident patients was hemodialysis (HD) (85%), while peritoneal dialysis (PD) was only 15%; pre-emptive transplantation was a very unusual modality. The prevalence of ESRD patients at 31 December was 693 pmp in 1996 and 827 pmp in 2001; among dialysis patients, the corresponding rates were 575 pmp and 657 pmp, respectively. Consequently, the number of dialyzed patients increased, respectively, from 28892 to 37919. The prevalent dialysis modality was bicarbonate dialysis in 74% of cases, followed by hemodiafiltration (HDF) in 15%, continuous ambulatory peritoneal dialysis (CAPD) in 7% and APD in 3%. The gross mortality rate in dialyzed patients was stable during this period, at approximately 14%, the main causes of death being cardiovascular diseases and cachexia.

[Hemodialysis access recirculation]. / Il fenomeno del ricircolo in corso di emodialisi (Hemodialysis Vascular Access Recirculation).

Vascular access recirculation (R) allows the evaluation of the adequacy of the extracorporeal blood circuit in dialysis patients. The test verifies the correct needle position in patients with arterovenous fistulae (AVF) and the effective function of central venous catheters. In clinically uncomplicated native fistulae, a normal R test could avoid more complex procedures like blood flow measure or angiography. The AVF recirculation has two components, vascular access recirculation (AR) and cardiopulmonary recirculation (CPR). While the first phenomenon is well known, the second remained undetected for many years resulting in wrong R calculations with false positives. Using the correct formula, the great majority of AVF resulted in zero recirculation. The presence of R reduces the dialysis efficiency to critical levels, mainly in unsuspected cases. Among the numerous available R tests, the urea test is the oldest and historically the most commonly used method, but unfortunately it is labor intensive, with low sensitivity and specificity and with delayed results. The "ultrasound dilution"method is considered the gold standard, easy to perform, with good repeatability, but it is expensive requiring a specific device. Finally, the glucose infusion test (GIT) is a new low-cost test with immediate results and a very low detection limit, with good repeatability and high specificity and sensitivity.