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.

Early initiation of cinacalcet for the treatment of secondary hyperparathyroidism in hemodialysis patients: a three-year clinical experience.

Despite the availability of standard therapy (vitamin D sterols and phosphate binders) for the treatment of secondary hyperparathyroidism (SHPT) in hemodialyzed (HD) patients, a significant percentage of patients still fail to achieve targets recommended by the Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Foundation for parathyroid hormone (PTH), calcium, and phosphorus. The calcimimetic cinacalcet (CN) has been shown to be an effective treatment for SHPT, significantly reducing serum PTH while simultaneously lowering calcium, phosphorus, and calcium-phosphorus product levels, thus increasing the proportion of patients achieving the K/DOQI targets for bone mineral parameters. The aim of this study was to evaluate if early treatment with CN had beneficial effects in HD patients with mild-to-moderate SHPT in whom conventional treatments had failed to achieve NKF-K/DOQI targets for PTH, serum-corrected calcium, and phosphorus while minimizing the risk of paradoxical hypercalcemia and/or hyperphosphatemia. Clinical practice data were collected monthly, starting from 6 months prior to, and up to 36 months after, the start of CN therapy. CN was started at a dose of 30 mg daily or every other day, and titrated thereafter to achieve intact PTH (iPTH) <300 pg/mL. The dose of concomitant vitamin D and phosphate binders were also adjusted in order to achieve K/DOQI targets. Data from 32 patients were collected, 28 of whom had been treated with CN for at least 36 months at the time of data analysis. At baseline, patients had serum iPTH >300 pg/mL (570 ± 295 pg/mL) and/or serum-corrected calcium >9.5 mg/dL. CN induced significant decreases in iPTH, calcium, and calcium-phosphorus product with respect to baseline levels. The percentage of patients within K/DOQI target levels at baseline, 12, 24, and 36 months was 0, 81.2, 83.3, and 86.2% for iPTH; 34.4, 65.6, 86.6, and 89.6% for serum-corrected calcium; 40.6, 56.2, 69.6, and 72.4% for phosphorus; and 37.5, 62.5, 80, and 82.7% for calcium-phosphorus product. The mean dose of CN at the end of the observation period was 38 mg/day. The mean dose of concomitant medication (calcitriol, Al-containing phosphate binders, and sevelamer) decreased from baseline to 36 months. Early treatment with CN in HD patients with SHPT increases the proportion of patients achieving and maintaining K/DOQI targets with a low dose of CN (38 mg/day). These results suggest that the metabolic control obtained with low-dose CN administered early in the course of SHPT can be maintained or increased over time.