Role of comprehensive geriatric assessment in low surgical risk older patients with aortic stenosis.

BACKGROUND: Among elderly with severe aortic stenosis (AS), Comprehensive Geriatric Assessment (CGA) originally contributed to address to transcatheter aortic valve implantation (TAVI) patients not suitable to surgical aortic valve replacement(SAVR). Nevertheless, TAVI has recently been proposed also in lower surgical risk patients. AIMS: To evaluate predictors of TAVI procedure and clinical outcomes among these patients. METHODS: For each patient ≥ 65 years with severe AS referring to our Cardiac Surgery Division, CGA was performed, including functional and cognitive status, comorbidity burden, frailty, nutritional status, gait speed, hand-grip strength and number of medications. Surgical risk was evaluated according to the Society of Thoracic Surgeons (STS) score (low-risk < 4%). Post-procedural outcomes (30-day survival and post-procedural complications) were obtained by medical records and a one-year follow-up assessed survival, and functional and cognitive performance. RESULTS: Among 154 subjects (mean age 82.9 years), 52 were at low-risk according to STS score. 32 patients were addressed to TAVI, 20 to SAVR. Variables significantly associated with TAVI-approach were lower gait speed (p 0.030) and higher number of medications (p 0.015). Short and long-term outcomes did not differ between groups. DISCUSSION: Among CGA variables, gait speed and number of medications were associated with the decision to perform TAVI instead of SAVR, even in patients at low surgical risk. 30-day and one-year survival and one-year functional and cognitive decline were similar between groups, despite a relevant prevalence of frailty in the TAVI group. CONCLUSIONS: We suggest that gait speed and number of medications should be considered in selecting appropriate candidates to TAVI among low surgical risk patients.

Risk management of renal biopsy: 1387 cases over 30 years in a single centre.

BACKGROUND: Although renal biopsy is largely employed, even in old patients with systemic diseases, few clinical studies have addressed its risk management. We aimed to obtain a comprehensive assessment of safety/utility ratio of percutaneous renal biopsy. PATIENTS AND METHODS: Retrospective review of all the 1387 patients who consecutively underwent renal biopsy in a single centre over three decades (1973-2002) was made, with calculation of complications, multivariate logistical analyses to evaluate risk factors of complications, and rate of alteration of clinical hypotheses by pathological diagnosis. RESULTS: There were no deaths and five major complications, (0.36%). One nephrectomy (0.07%), two surgical revisions (0.1%) and two arterial-venous fistulae (0.1%). There were also 337 minor bleeding complications (24.2%) (16.4% gross haematuria and 7.8% clinically relevant haematomas needing at least prolonged bed rest). Multivariate analyses demonstrated that the risk for complications was significantly increased by systemic autoimmune diseases with odds ratio (OR) 2.06, 95% confidence interval (CI)=1.40-3.01, end-stage kidney/acute-tubular necrosis (OR 2.96, 95% CI=1.19-7.30), and prolonged bleeding time test (BTT) (OR 1.87, 95% CI=1.17-2.83). Among the 1288 cases in which a clinical hypothesis before renal biopsy was recorded, renal pathology changed previous diagnoses in 423/1,288 (32.8%) of cases. CONCLUSIONS: Risk assessment demonstrates that renal biopsy is a useful procedure with a low incidence of serious complications. Platelet function is the only modifiable factor significantly related to bleeding complications, suggesting the need for a more standardized alternative to the BTT. Platelet function should be evaluated to select low-risk patients for renal biopsy as 'a day case procedure', in order to build adequate risk management strategies.

Analysis of red cell parameters on the Sysmex XE 2100 and ADVIA 120 in iron deficiency and in uraemic chronic disease.

OBJECTIVE: The percentage measurement of hypochromic red cells (HYPO) and reticulocyte haemoglobin content (CHr) using the ADVIA system has recently been validated as a useful tool in indicating iron deficiency, also in cases of chronic diseases such as renal failure. The aim of this study was to evaluate the extent to which the red cell parameters, RBC-Y and RET-Y, provided by Sysmex XE 2100, correlate with HYPO and CHr. MATERIAL AND METHODS: The laboratory markers of iron status were evaluated together with HYPO, CHr, RBC-Y and RET-Y in 92 healthy subjects (C), 42 iron-deficient patients (ID) and 88 uraemic patients receiving regular dialysis treatment (RDT). RESULTS: In ID patients, increased HYPO and decreased RBC-Y, CHr and RET-Y values, with no overlapping with reference values, were found and a significant correlation was present between ADVIA 120 and Sysmex indices (p<0.001 for each correlation). In RDT patients, HYPO median values were increased with a wide distribution of values (95 % reference range = 0.7-27.5 % and 0.7-22.6 % in men and women, respectively). In contrast, RBC-Y was normal/increased (95 % reference range = 169.4-191.1 and 168.7-190.5 in men and women, respectively), even though there was a significant correlation between them (p<0.001). CHr and RET-Y values were within the reference range; moreover, in these patients mean cell volume of red cells and of reticulocytes (MCV and MCVr) median values were increased. CONCLUSIONS: This study confirmed the validity of RBC-Y in the management of ID, but not in RDT, where the diagnostic power of RBC-Y as an index of cell hypochromia is limited owing to high MCV values.

Opinions on renal transplantation and organ donation in high school students in two large northern (Torino) and southern (Napoli) Italian cities.

UNLABELLED: Organ shortage for transplantation has focused attention on educational interventions. Italy is a nonhomogenous country whose cultural and economic differences are reflected in the health-care system: dialysis is mainly public in the north versus private in the south; and transplantation rates display a wide range from 3.4 to 37.8 per million people in 2002. The aim of the present study was to analyze the opinions of population of high school students (last two years) in two large cities: northern (Torino) and southern (Napoli) Italy, as a knowledge base for a randomized controlled trial on the efficacy of educational interventions on renal replacement therapy and organ donation, targeted to high school students. METHODS: This preliminary study included eight public high schools that completed a first and anonymous semistructured questionnaire. Five hundred and eighty nine questionnaires were retrieved in Torino and 539 in Napoli. In both cities most students answered that they would give a kidney to a brother, sister, or partner needing dialysis (Torino: yes 80.6%; no 2.2%, uncertain-blank 17.2%; Napoli: yes 86.1%, no 1.1%; uncertain-blank 12.8%). Only 36.3% of the students in Torino and 37.7% in Napoli answered that they would consent to organ donation, if they had to choose for a strict relative with brain death. Opposition was 28% in Torino and 23.7% in Napoli; 35.7% in Torino and 38.6% in Napoli were blank-uncertain. These data underline the need for detailed information on the opinions of the overall population as basis for tailored educational campaigns.

Efficacy of an educational program on dialysis, renal transplantation, and organ donation on the opinions of high school students: a randomized controlled trial.

AIM: Organ shortage is a rate-limiting factor for transplantation. The aim of this study was to evaluate the impact of an educational program targeted to high school students on opinions concerning organ donation. METHODS: Sixteen public high schools in Torino, Italy, were randomized (2001 to 2002) as interventions (n = 8) or controls (n = 8). Intervention was composed of first questionnaire, first lesson (one to two classes; 2 hours, by a trained nephrology fellow); second lesson (all classes together; coordinated by a nephrologist, with patients and trainees); second questionnaire. Control included questionnaires. Statistical analysis compared the opinions in the questionnaires after stratification for age, sex, and type of school. RESULTS: Fourteen schools completed the program (seven interventions: 937 first and 808 second questionnaires; controls: 739 and 659). Television (82.5%) and newspapers (43.2%) were the main sources of information; knowledge on renal transplantation (grafts feasible per patient, average duration) was low; only 12.2% of the students gave correct answers. The opinions on living donation were highly positive (76.8%) with no difference in control, intervention schools, first and second questionnaires, according to sex, age, or type of school. The opinions on cadaveric transplantation were affected by the educational intervention with a drop in negative answers (from 33.7% to 16%), with an increase in positive (from 31.5% to 42.9%) and in uncertain ones (from 34.8% to 41.1%) among the intervention schools; 98% of the students appreciated the program. CONCLUSION: The positive effect on student opinions suggests the need to develop educational approaches as a part of our routine clinical work.

How many organs should one patient receive? The ethics of transplantation in the medical school.

BACKGROUND: Interest in the humanities in the medical school is growing; while several medical schools, mainly of Anglo-Saxon background, have developed dedicated courses, the experience in Italy is limited. METHODS: Since the academic year 2000 to 2001, a discussion of ethical problems was implemented in the nephrology course (fourth year of the Medical School of Torino, Italy; overall 6 years). In 2002 to 2003, a case entitled "Retransplantation of Multiple Organs (Prog Transplant 2002)" was discussed in 2 hours of small-group tutorial teaching: a boy received a renal graft at age 5, failed at age 7 due to recurrent glomerulonephritis, required a heart-kidney graft at age 11, and a second heart-kidney graft at 17. Student opinions were gathered by anonymous semistructured questionnaires at the beginning of the lessons as a basis for discussion. RESULTS: Following the lessons all students returned the questionnaires (n = 104). In the absence of competition for allocation, retransplantation was approved by 76.2%, unacceptable for 1% (22.9% uncertain-blank). With a waiting list of 10 patients, the opinions changed: 32.4% approved transplantation, 6.7% didn't approve it, 60.9% were uncertain. A theoretical categorization into deontological or utilitaristic approaches favored the first (41.9% vs 26.7%), with a high prevalence of blank-uncertain (31.5%); 21.9% of the students would change their opinion was that study head of the Transplant Department. CONCLUSION: Ethical aspects of the medical profession have been discussed with interest by medical school students; the high prevalence of uncertain answers and requests to develop specific tools underline the importance of this educational approach.

Kidney vending: opinions of the medical school students on this controversial issue.

BACKGROUND: In this era of globalization, in which different cultural and economic barriers are progressively abated, in the context of the development of rapid information networks such as the Internet, physicians are increasingly challenged by clinical and ethical questions. Kidney vending, banned in some countries, legal or tolerated in others, may be the prototype of the ethical aspects of health-care globalization. METHODS: To test the interest and the opinions of medical school students, a simulated case was proposed to students attending a seminar within the nephrology course fourth year of the Medical School of Torino, san Luigi): an Italian patient comes to the nephrologist's office asking for advice on the possibility to legally buy a kidney in a foreign country. The 43 students attending the lesson answered a semistructured questionnaire (15 boys, 28 girls, of median age 23 years). Attendance was within the usual standards (50 students inscribed per year). From the clinical point of view, 11.6% were favorable to kidney vending, 51.2% were contrary, 37.2% were uncertain. From the ethical point of view, no student was pro, 81.4% were contrary, and 18.6% were uncertain. The open comments underline the importance of patient self-determination and of informed consent. Similar opinions were recorded in a nonstructured question: "What should physician's attitude be, in the face of a choice he/she doesn't share?" CONCLUSION: Students' uncertainties and doubts underline the need to discuss ethical scenarios in the clinical teachings of the medical school.

To give or to receive? Opinions of teenagers on kidney donation.

BACKGROUND: The attitude toward living donation varies widely in the world, for economic and cultural reasons. In Italy, as in other Mediterranean settings, the role of living kidney donation is minor. AIM: To analyze the reasons for this attitude, we gathered data in a general population sample of high school students in a large northern Italian industrial city (Torino, about 900,000 inhabitants). METHODS: Semistructured questionnaires (n = 1676), gathered in 2001 to 2002 in 14 high schools, in the context of an educational program on dialysis, renal transplantation, and organ donation, were analyzed presumably reflecting opinions gathered before the educational intervention. RESULTS: Most students, in the case of a close relative or partner needing dialysis, answer that they would donate a kidney (yes: 78.2%, no: 2.9%, uncertain-blank: 18.9%); receiving a living donor kidney is felt as disturbing: only 57.5% of the students would accept it (no: 5.9%, uncertain-blank: 36.6%), mainly because of fear of long-term problems for the donor. Donation from an older to a younger person is seen more positively than vice versa. CONCLUSION: In our settings, the attitude of the teenagers on living donation is positive; however, while "giving" is positively seen, the presence of unresolved fears is witnessed by the lower acceptance of the idea of "taking." These data suggest to focus on the risks of kidney donation in educational campaigns and in patient-physician information. The positive attitude shared by the teenagers supports the working hypothesis that lack of information is one of the determinants of the low living donor transplantation rate in our area.

Teaching technology with technology: computer assisted lessons in the medical school the first Italian experience in nephrology and dialysis.

BACKGROUND: Dialysis is often neglected in academic teaching. At the University of Torino, Italy, teaching Nephrology (4th year of Medical School) consists of 21 hours of formal lessons, 10 hours/student of interactive lessons (4/10 dedicated to dialysis) and 10 optional lessons (3 regarding dialysis). Interactive and optional lessons widely employ computer assisted teaching. Aim of the study was to evaluate student satisfaction on this approach. METHODS: Student satisfaction was assessed on 4 sample lessons (166 students), by two short dedicated questionnaires (0-10 scale, open questions). RESULTS: High scores were given to the dialysis lessons (median 8/10). Computer assisted interface (median 8/10, range 6-10) was of help in check of knowledge in real time (86%), enhancing participation (61%); 62% suggest extending this experience to selected courses, 38% to all. CONCLUSIONS: Medical students consider dialysis an important part of the academic teaching of Nephrology; new interfaces may help to enhance student satisfaction.

Clinical relevance of hemochromatosis-related HFE C282Y/H63D gene mutations in patients on chronic dialysis.

BACKGROUND: The actual prevalence and the clinical relevance of gene mutations of HFE (which are linked to hemochromatosis) have not yet been established in patients on chronic dialysis. On the basis of theoretical premises, it could be hypothesized that these genetic determinants might influence the response to iron intake and the susceptibility for iron overload in patients in parenteral iron therapy. Furthermore, carriers for these mutations might be prone to develop sporadic porphyria cutanea tarda and cardiovascular events. METHODS: C282Y/H63D mutations of HFE gene were evaluated in 132 patients (34 in peritoneal dialysis, 98 in HD) and correlated with biochemical parameters of iron status (ferritin (FER) concentration and transferrin saturation (TSAT)), red cell parameters (red cell size and hemoglobin content), erythropoietin (EPO) dosage, major cardiovascular events and C-reactive protein as marker of chronic inflammation, in patients without iron therapy and after i.v. iron supplementation (< or = 60 mg/week) and with the presence of biopsy-proven porphyria. RESULTS: C282Y heterozygous mutation was found in 8/132 (6.6%); H63D homozygous and heterozygous mutations were found in 3/132 (2.3%) and 22/132 (16%) patients, respectively. Two patients (1.5%) showed double heterozygosis. No differences in baseline serum FER and TSAT and the other biochemical and clinical parameters were found in patients bearing mutations alleles nor after continuous iron therapy at low dosages. However, the prevalence of patients capable of maintaining normal hemoglobin (Hb) level without EPO therapy is increased in the C282Y-mutated patients. Only 1 patient out of the 4 with biopsy-proven porphyria cutanea tarda was bearing gene mutations (H63D heterozygosis). CONCLUSION: C282Y/H63D HFE gene mutations do not seem to be related to major abnormalities in biochemical parameters of iron status in dialysis patients without iron therapy or after i.v. iron supplementation, granted that low dosages are employed. Obviously, as our patients were exposed to a relatively uniform iron regimen in our clinical center (< or = 60 mg/week), it is unclear if other dosing regimens will unmask clinically significant differences between the heterozygotes and normals. The fact that the C282Y-mutated patients more frequently maintain high Hb values without EPO is interesting as could suggest a better use of available iron for erythopoiesis, but needs to be confirmed in larger samples. No clear association is demonstrated with porphyria cutanea tarda and major cardiovascular events.