Increase of continuous treatments and regional citrate anticoagulation during renal replacement therapy in the ICUs of the North-West of Italy from 2007 to 2015.

BACKGROUND: Few reports have addressed the change in renal replacement therapy (RRT) management in the Intensive care Units (ICUs) over the years in western countries. This study aims to assess the trend of dialytic practice in a 4.5-million population-based study of the northwest of Italy. METHODS: A nine-year survey covering all the RRT provided in the ICUs. Consultant nephrologists of the 26 Nephrology and Dialysis centers reported their activities in the years 2007, 2009, 2012, and 2015. RESULTS: From 2007 to 2015 the patients treated increased from 1042 to 1139, and the incidence of RRT from 254 to 263 cases/10^6 inhabitants. The workload for dialysis center was higher in the larger hub hospitals. RRT for acute kidney injury (AKI), continuation of treatment in chronically dialyzed patients, or extrarenal indications accounted for about the stable rate of 70, 25 and 5% of all RRT sessions, respectively. Continuous modality days increased from 2731 days (39.5%) in 2007 to 5076 (70.6%) in 2015, when the continuous+prolonged treatment days were 6880/7196 (95.6% of total days). As to RRT timing, in 2015 only the classical clinical criteria, and no K-DIGO stage were adopted by most Centers. As to RRT interruption, in 2015 urine volume was the first criterion. Implementation of citrate anticoagulation (RCA) for RRT patients significantly increased from 2.8% in 2007 to 30.9% in 2015, when it was applied in all 26 Centers. CONCLUSIONS: From 2007 to 2015, current practice has changed towards shared protocols, with increasing continuous modality and RCA implementation.

Does Mediterranean Adequacy Index Correlate with Cardiovascular Events in Patients with Advanced Chronic Kidney Disease? An Exploratory Study.

The Mediterranean Diet (MD) is a healthy dietary pattern, demonstrated to reduce the risk of cancer, diabetes, cardiovascular and neurodegenerative diseases, and early death. The Mediterranean Adequacy Index (MAI) is used to measure adherence to the MD in perspective studies in the general population and correlates with cardiovascular events. The aim of this study was to calculate the MAI among patients with advanced chronic kidney disease (CKD) and correlate it with traditional uremic, microbiota-derived, and proatherogenic toxins as well as nutritional status, quality of life, and cardiovascular events. A total of 60 adult patients with advanced CKD were enrolled and their MAI was calculated. According to the median value, patients were divided into lower (l-MAI, <1.80) and higher (h-MAI, ≥1.80) MAI groups. Biochemical parameters, microbiota-derived and proatherogenic toxins (p-Cresyl sulphate, Indoxyl-sulphate, and Lipoprotein-associated phospholipase A2), nutritional status, quality of life, and cardiovascular events that occurred in the previous three years were recorded. The mean value of the MAI was 2.78 ± 2.86. The MAI was significantly higher in foreigners (median (IQR) 6.38 (8.98) vs. 1.74 (1.67), p < 0.001) and diabetic patients. The l-MAI and h-MAI groups had similar routinary blood, p-Cresyl-sulphate, Indoxyl-sulphate, and Lp-PLA2 as well as nutritional status and quality of life parameters. The MAI was not associated with previous cardiovascular events and did not correlate with cardiovascular events in CKD patients. New and nephro-tailored indexes are warranted to evaluate nutritional therapy in CKD patients.

Probiotics-Supplemented Low-Protein Diet for Microbiota Modulation in Patients with Advanced Chronic Kidney Disease (ProLowCKD): Results from a Placebo-Controlled Randomized Trial.

The probiotics-supplemented low-protein diet in chronic kidney disease (ProLowCKD) was a single-centre, double-blind, placebo-controlled, randomised trial that was conducted to investigate whether the association between a low protein diet (LPD) and a new formulation of probiotics (Bifidobacterium longum and Lactobacillus reuteri) was effective at reducing traditional uremic, microbiota-derived, and proatherogenic toxins in sixty patients affected by advanced CKD. After 2 months of a LPD-a reduction in blood urea nitrogen (52 ± 17 vs. 46 ± 15 mg/dL, p = 0.003), total cholesterol (185 ± 41 vs. 171 ± 34 mg/dL, p = 0.001), and triglycerides (194 ± 148 vs. 161 ± 70 mg/dL, p = 0.03) was observed; 57 subjects were then randomized to receive probiotics or a placebo for the subsequent 3 months. A total of 27 patients in the placebo group showed increased serum values of total cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.01), LDL cholesterol (169 ± 36 vs. 185 ± 40 mg/dL, p = 0.02), lipoprotein-associated phospholipase A2 (155.4 ± 39.3 vs. 167.5 ± 51.4 nmol/mL/min, p = 0.006), and indoxyl-sulphate (30.1 ± 17.6 vs. 34.5 ± 20.2 µM, p = 0.026), while the 24 subjects in the probiotics group showed a trend in the reduction of microbiota toxins. A reduction of antihypertensive and diuretic medications was possible in the probiotics group. This study shows that associating probiotics to LPD may have an additional beneficial effect on the control and modulation of microbiota-derived and proatherogenic toxins in CKD patients.

Compliance, Adherence and Concordance Differently Predict the Improvement of Uremic and Microbial Toxins in Chronic Kidney Disease on Low Protein Diet.

BACKGROUND: In medicine, "compliance" indicates that the patient complies with the prescriber's recommendations, "adherence" means that "the patient matches the recommendations" and "concordance" means "therapeutic alliance" between patient and clinician. While a low protein diet (LPD) is a cornerstone treatment of chronic kidney disease (CKD), monitoring the actual performance of LPD is a challenge. PATIENTS: Fifty-seven advanced CKD adult patients were enrolled and LPD prescribed. Compliance was evaluated through the normalized protein catabolic rate (nPCR), adherence by the dietitian by means of a 24-h dietary recall and concordance by the nephrologist during consultations. Traditional parameters as well as total p-Cresyl Sulphate (t-PCS), total Indoxyl Sulphate (t-IS) and Lipoprotein-associated phspholipase A2 (Lp-PLA2) were compared between adherent/not adherent and concordant/not concordant subjects at enrolment and after two months. RESULTS: nPCR, blood urea nitrogen, cholesterol and triglycerides significantly decreased in all patients. t-PCS and t-IS decreased among adherent subjects. Lp-PLA2, t-PCS, free-PCS and t-IS decreased among concordant subjects, while these increased in non-concordant ones. CONCLUSION: This study demonstrates that LPD may improve the control of traditional uremic toxins and atherogenic toxins in "adherent" and "concordant" patients. A comprehensive and multidisciplinary approach is needed to evaluate the compliance/adherence/concordance to LPD for optimizing nutritional interventions.

Ionizing radiation exposure from dialysis tunneled catheters procedures: European directive and legal implications.

BACKGROUND: Advances in medical imaging and interventional procedures have been associated with increased exposure to ionizing radiation. Thus, the International Commission on Radiological Protection (ICRP) established uniform safety standards to protect the general public against the dangers arising from ionizing radiations. In Europe, the ICRP standards are listed in the European Directive 2013/59/EURATOM, which should be transposed into national legislation by member states. They require that the administered dose must be part of the radiological report and identify the practitioners' responsibilities in justifying and optimizing the dose and correctly informing the patient.Despite these indications, the literature lacks information about the dose from fluoroscopically inserted dialysis tunneled central venous catheters (td-CVC). This study aimed to quantify the effective dose and organ dose to relevant organs in td-CVC to comply with the EU statements. METHODS: We revised fluoroscopically-guided procedures of td-CVC insertion, considering dose per area product, fluoroscopic time, effective dose, organ dose, and anatomical district. We also compared these parameters with those of fluoroscopically inserted oncological central venous devices (Port-a-cath). RESULTS: The dose-area product, fluoroscopic time, and organ dose for td-CVC were 13 ± 22.2 Gy*cm2, 81 ± 129 s, and 1.9 ± 3.3 mSv. The radiological parameters for the left internal jugular, subclavian and femoral veins were similar but higher than for the right internal jugular vein. The radiological parameters were significantly higher for td-CVC than for Port-a-cath. CONCLUSIONS: Fluoroscopically inserted td-CVC are associated with a relatively low dose of ionizing radiation, with considerable variability due to the anatomical puncture site and previous accesses' history. In light of the European Directive, it is a concern for nephrologists to be aware of the administered ionizing dose to comply with their legal responsibilities.

Lipoprotein-associated phospholipase A2 predicts lower limb ischemia in hemodialysis subjects.

Hemodialyzed patients (HD) have high prevalence of peripheral arterial disease. In the general population, lipoprotein-associated phospholipase A2 (Lp-PLA2 ) is associated with peripheral arterial disease but no data are available for renal subjects. The aim of this study was to evaluate the relationship between Lp-PLA2 and lower limb ischemia among dialyzed patients. One hundred and two dialyzed subjects, with median (IQR) age of 71 (59-78) years, enrolled in June 2013 and followed until June 2018, were investigated for Lp-PLA2 activity and the occurrence of peripheral arterial disease and lower limb ischemia. The median (IQR) levels of Lp-PLA2 were 184 nmol/min/mL (156.5-214.5). The 43 HD patients with abnormal Lp-PLA2 activity (>194 nmol/min/mL) had higher levels of total and LDL-cholesterol, ApoB/A1 ratio, and higher occurrence of lower limb ischemia during the follow up (44% vs 17%, P = .003). In multivariate analysis, Lp-PLA2 activity (P = .018) and diabetes (P < .001) were independently associated with time to lower limb ischemia, and when the presence of previous PAD was added to the multivariate model, only presence of previous PAD (P < .001) and Lp-PLA2 (P = .003) remained associated. Lp-PLA2 is an independent predictor of lower limb ischemia in dialyzed patients.

Lipoprotein-associated phospholipase A2 predicts cardiovascular events in dialyzed patients.

BACKGROUND: Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a serine lipase that enhances the instability of the atherosclerotic plaques. While in the general and cardiac population Lp-PLA2 is recognized as an important determinant of cardiovascular (CV) accidents, no data are available for the renal population. The aim of this study was to evaluate the relationship between Lp-PLA2 and acute CV events in hemodialyzed patients. METHODS: We enrolled 102 dialyzed patients, 63% male, age 71 years (59-78), 35% with diabetes, 54% hypertension, 40% coronary artery disease and 31% peripheral vascular disease. They were investigated for Lp-PLA2 (cut-off < 194 nmol/min/ml), lipoprotein profile and the occurrence of acute CV events and death in the subsequent 3 years of follow-up. RESULTS: The median (interquartile ranges) levels of Lp-PLA2, total-, HDL-, LDL-cholesterol and ApoB/ApoA lipoprotein ratio were 184.5 (156.5-214.5) nmol/min/ml, 158 (127-191) mg/dl, 41 (33-51) mg/dl, 79 (63-102) mg/dl and 0.72 (0.58-0.89), respectively. In 42% of patients, Lp-PLA2 was > 194 nmol/min/ml and total- and LDL-cholesterol were higher, as well as CV morbidity and mortality. During follow-up, 51% of patients developed at least one CV event; the median survival time was 36 months, with a total and CV mortality of 42 and 29%, respectively. At multivariate Cox regression, Lp-PLA2 > 194 nmol/min/ml (HR = 2.98, p = 0.005), age (HR = 1.03, p = 0.029), diabetes (HR = 2.86, p = 0.002) and hypertension (HR = 2.93, p = 0.002) were independently associated with time to CV events. CONCLUSIONS: Lp-PLA2 activity is elevated among dialyzed patients and is an independent risk factor for acute CV events in a mean follow-up of 3 years.

[Efficacy of SUPRA HFR in the treatment of acute renal damage during multiple myeloma].

Acute Kidney Injury (AKI) is a frequent complication of multiple myeloma (MM) with unfavorable prognostic significance. Light chains removal, combined with hematological therapy (CT) seems to offer significant benefits to renal function recovery (RFR). The SUPRA HFR, through the combination of high cut-off membrane without albumin loss and adsorbent cartridge, represents one of the "emerging" light chain removal methods. We report our multicentric retrospective experience with SUPRA HFR in 7 MM patients. At the end of the treatment with SUPRA HFR a significant reduction in serum free light chains compared to baseline was observed (min 24%; max 90%; median 74%). Despite a not always early start of the treatment, all patients recovered renal function with withdrawal from dialysis in 6/7 cases. Our preliminary experience of a combination of SUPRA HFR treatment with CT in 7 MM patients with AKI showed a significative renale functional recovery, with favourable cost/benefit ratio and a simple treatment schedule. These encouraging data suggest to further extend such treatment option, waiting for larger studies in this field.

Vitamin K Antagonist Therapy Is a Risk Factor for Ulcer Development and Death Among Dialyzed Patients.

Peripheral artery disease is a common complication among dialyzed patients. Since Vitamin K antagonists promote metastatic calcifications and these are the main determinants of vascular damage, we investigated their role in the development of lower limb ulcers in dialyzed patients. We retrospectively enrolled 316 dialyzed patients, aged 68 ± 15 years, 65% male, 32% diabetic, 43% with ischemic heart disease and followed them for 36 ± 25 months. 60 patients assumed Vitamin K antagonists: they were older, with a higher prevalence of heart disease, at greater risk of death and they developed more ulcers and underwent more lower limb amputations compared to the rest of our cohort. Peripheral artery disease, Vitamin K antagonists and diabetes were independent risk factors for foot lesions. In addition, Vitamin K antagonists were also an independent risk factor for death. Vitamin K antagonists are a potent independent risk factor for the development of the uremic foot syndrome and death.

Radiation exposure from medical imaging in dialyzed patients undergoing renal pre-transplant evaluation.

BACKGROUND AND AIM: Ionizing radiation exposure from medical procedures is rising sharply-the per-capita annual effective dose in the US is 3.0 millisieverts (mSv). Hemodialyzed and kidney transplanted patients receive still higher doses of ionizing radiation due to the presence of multiple comorbidities. The aim of this study was to assess the cumulative effective dose (CED) among dialyzed patients undergoing renal pre-transplant evaluation. PATIENTS AND METHODS: We evaluated 70 hemodialysis patients between June 2009 and December 2014, aged 46.4 ± 12.0 years. The number and type of radiologic procedures were collected through the Radiology Information System. CED was expressed as total mSv/patient and annual CED (mSv/patient/year). RESULTS: A total of 744 radiologic procedures were performed, accounting for 3869 mSv of ionizing radiation: conventional radiology, computed tomography and nuclear medicine accounted for 78, 14 and 8 % of the procedures, but they represented, respectively, 8, 83 and 9 % of the total CED. The mean (median) annual CED was 35 (7) mSv/patient/year, while total CED was 72 (32) mSv/patient. Thirty-seven patients were active waitlisted and received 47 (10) mSv during the pre-transplant evaluation and 36 (5) mSv during the waiting phase to maintain active status. Concerning cancer risk, 4 (7 %) patients were classified at low risk (<3 mSv/year), 19 (35 %) at moderate risk (3 to <20 mSv/year), 8 (15 %) at high risk (20 to <50 mSv/year), and 23 (43 %) at very high risk (≥50 mSv/year). CONCLUSIONS: Our study demonstrated that during renal pre-transplant evaluation, dialyzed patients receive a high dose of ionizing radiation. Considering that transplanted individuals have a high incidence of cancer due to multifactorial etiology, it is mandatory to reduce the ionizing radiation imaging.

Polymorphisms Associated with Increased Cardiovascular Risk in the General Population do not Predict Acute Events in Hemodialysis Patients.

BACKGROUND: Cardiovascular diseases are the leading cause of morbidity and mortality in hemodialysis patients (HP). The aim of the study was to analyze a series of polymorphisms (known to be associated with increased cardiovascular risk in the general population) in HP, in order to better understand the mechanisms of cardiovascular disease and to find new prevention strategies. METHODS: 102 hemodialysis patients were investigated for polymorphisms associated with increased cardiovascular risk in unselected population (FV Leiden R506Q; FV H1299R; FII G20210A; PAI-1 var 4G/5G; GpIIIA T1565C; FXIII var G/T; ß-FIBRINOGENO var G/A; ACE I/D; AGT var M/T; ATR-1A1166C; APOE T112C; APOE T158C; MTHFR C677T; MTHFR A1298C; CBS 844ins68). RESULTS: No difference was observed in the prevalence of the analysed polymorphisms between HP and Caucasian unselected population, with the exception of FV H1299R, PAI-1 (4G/5G), and Factor XIII V34L, which were significantly higher in HP. However none of the genetic factors analysed was associated in HP with the cardiovascular events (non-fatal and fatal) recorded at the time of recruitment or during the eighteen months -follow up. CONCLUSIONS: In HP, the traditional genetic risk factors for cardiovascular disease are not able to predict acute cardiac events, peripheral vascular events, and cerebral vascular events recorded during a follow up period of eighteen months.

Lipoprotein profile, lipoprotein-associated phospholipase A2 and cardiovascular risk in hemodialysis patients.

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality in hemodialysis patients; the increased risk of cardiovascular disease is due to accelerated atherosclerosis, inflammation and impaired lipoprotein metabolism. We aimed to evaluate lipoprotein-associated phospholipase A2 (Lp-PLA2) and some pro-inflammatory aspects of the lipoprotein profile in dialyzed patients in order to evaluate the relationship with the accelerated atherosclerosis and vascular accidents. METHODS: In 102 dialysis patients and 40 non-uremic controls, we investigated the lipoprotein plasma profile, high sensitivity C-reactive protein (CRP), ceruloplasmin and serum amyloid A protein (SAA), and followed patients for 1 year to analyze the risk of acute cardiovascular events. RESULTS: Total cholesterol, low-density lipoprotein and high-density lipoprotein plasma levels were significantly lower in uremic patients than controls, whereas CRP, SAA, ceruloplasmin, Lp-PLA2 and their ratio with apolipoprotein A1 were significantly higher. Patients with Lp-PLA2 levels >194 nmol/min/ml had more acute cardiovascular events than patients with lower values. CONCLUSION: Our results show that in dialysis subjects: (1) low-density lipoproteins show a more atherogenic phenotype than in the general population; (2) high-density lipoproteins are less anti-inflammatory; (3) Lp-PLA2 could potentially be used to evaluate cardiovascular risk.

[Acute pielonephritis and renal abscesses in Piedmont and Aosta Valley]. / Indagine sulla pielonefrite acuta e sugli ascessi renali in Piemonte e Valle d'Aosta.

The Piedmont Group of Clinical Nephrology compared the activity of 18 nephrology centers in Piedmont and Aosta Valley as regards acute pielonephritis (APN). Data from more than 500 cases per year of APN were examined. The microbial spectrum of APN consists mainly of Escherichia coli and Klebsiella pneumoniae. Diagnosis was based on both clinical and radiological criteria in most of the centers (computed tomography-CT o Magnetic Resonance Imaging-MRI). In four centers diagnosis was made with the radiological criteria and in one center only with the clinical features. CT and MRI were performed in about 47% and 44% of cases respectively. Urine culture was positive in 22 up to 100% of cases. The most commonly used antibiotics were fluoroquinolones (ciprofloxacin or levofloxacin) and ceftriaxone (50% of centers) or amoxicillin/clavulanic acid (25% of centers). In 75% of the centers, patients received a combination of two antibiotics (aminoglycoside in 22% of them ). In 72% of the centers, almost 50% of the patients were re-examined, while 38.8% of centers re-examined all the patients. Renal ultrasound was inappropriate to identify abscesses. The mean of patients in whom renal abscesses were detected by CT or MRI was 18.2%. The analysis shows a high variability in the way of diagnosing and treating APN in Piedmont and Aosta Valley regions. This suggests that even if APN is a frequent pathological condition, practical recommendations are required.

Stenotrophomonas maltophilia: an emerging pathogen in dialysis units.

Infection is an important cause of morbidity and mortality among patients with end stage renal disease. Stenotrophomonas maltophilia is an unusual yet emerging pathogen in dialysis units. We performed a systematic PubMed/Medline and Scopus review of peer-reviewed English papers on S. maltophilia infections among patients undergoing chronic dialysis, with regard to vascular accesses, systemic infections and environment contaminations. Moreover, we suggest a treatment algorithm to preserve the patient and the permanent dialysis catheters.

Leclercia adecarboxylata and catheter-related bacteraemia: review of the literature and outcome with regard to catheters and patients.

Infection is a common complication in patients carrying a central venous catheter (CVC) and is associated with increased morbidity and mortality. Leclercia adecarboxylata is an unusual but emerging pathogen in healthy and immunocompromised patients. We report a case of L. adecarboxylata bacteraemia in a patient with a haemodialysis tunnelled CVC. In accordance with the susceptibility to the tested antimicrobials, a long-course treatment with intravenous gentamicin plus amoxicillin-clavulanic acid and gentamicin-lock therapy was adopted. The patient had a full recovery and the catheter was not removed. We also performed a systematic PubMed/Medline and Scopus review of peer-reviewed English papers on L. adecarboxylata infections, focusing on bacteraemia in patients with different types of CVCs. Moreover, we suggest a treatment algorithm to preserve the patient and maintain the CVC.

Report of a transient increase in tunneled catheter infections following dialysis facility transfer to a prefabricated structure.

PURPOSE: Despite the efforts to promote the native artero-venous fistula as dialysis access, the use of tunneled central venous catheters (tCVC) is increasing. Main complications remain infections of the access, and the environment plays an important role in determining them; however, no studies are available that report dialysis provided in prefabricated temporary buildings. The aim of our study was to assess the incidence of tCVC infections in a container building. METHODS: Since May 2009 our Dialysis Center has been located in a container building. The occurrence of local and systemic infections of tCVC when dialysis was provided in the container was compared with the previous two years, when dialysis was provided at the "Home" center. Each year was also divided into semesters to maintain the temporary relationship between the new location and the infections. RESULTS: tCVCs represented approximately 13% of all vascular accesses. In the first six months in the temporary building, 50% of patients presented infections, compared to 13% to 20% during the other periods (P=0.02). In the first six months in the container the incidence of infections was 1.44 per 1000 catheters-days, higher than in any other semester (P=0.02). More infections requiring systemic antibacterial agents occurred over this period. CONCLUSIONS: Our study demonstrates that, when a dialysis center is moved to a prefabricated temporary building, the likelihood of tCVC infections increases within the initial months and returns back to the previous levels after a period of adaptation.

[Renal biopsy practice in Piedmont and Valle d'Aosta]. / Indagine sulle modalità di esecuzione delle biopsia renale in Piemonte e Valle d'Aosta.

In 2010 a questionnaire was administered to the renal units of Piedmont and Valle d'Aosta to analyze their procedures for renal biopsy (RB). Seventy-eight percent of units performed RBs, 57% for more than 20 years, but only 43% performed at least 20 BRs per year. 20/21 units performed RB in an inpatient setting and 1/21 in day hospital with the patient remaining under observation the night after. Thirty-two percent did not consider a single kidney as a contraindication to RB, 59% considered it a relative contraindication and 9% considered it an absolute contraindication. In 90.5% of units there was a specific protocol for patient preparation for RB and 86% used a specific informed consent form. Ninety-five percent of units performed ultrasound-guided RB, 60% of them using needle guides attached to the probe. In 81% of units the left side was preferred; 71% put a pillow under the patient's abdomen. All units used disposable, automated or semi-automated needles. Needle size was 16G in 29%, 18G in 58%, and both 16G and 18G in 14% of units; 1 to 3 samples were drawn. One third of units had a microscope available for immediate evaluation of specimen adequacy. After RB, 86% of units kept patients in the prone position for 2-6 hours and all prescribed a period of bed rest (at least 24 hours in 90.5%). 90.5% of units followed a specific postbiopsy observation protocol consisting of blood pressure, heart rate and red blood cell measurements at different times, and urine monitoring and ultrasound control within 12-24 hours (only half of them also employing color Doppler). One third of all units discharged patients after 1 day and two thirds after 2-3 days; all prescribed abstention from effort and from antiplatelet drugs for 7-15 days. In 9 units both RB and tissue processing and examination were done in the same hospital, while 12 units sent the samples elsewhere. 76% obtained results in 2-4 days, 19% in 6-7 days, and 5% in 10-15 days. Less than 20% of the interviewed operators were fully familiar with the clauses of hospital insurance securing their activity. Use of RB is widespread in Piedmont and Valle d'Aosta but its practice shows variation between centers.

Cumulative radiation dose from medical imaging in kidney transplant patients.

BACKGROUND: Although many patients undergoing kidney transplant are exposed to multiple examinations that increase cumulative effective doses (CEDs) of ionizing radiation, no data are available characterizing their total longitudinal radiation burden and relating radiation burden with risk factors for more exposure. METHODS: We did a retrospective cohort study of 92 patients (mean age 52 years; range: 20-75 years) who underwent kidney transplant at University Hospital, Novara, Italy, that evaluated all following medical imaging procedures involving ionizing radiation undergone beginning June 2007, and all subsequent procedures through August 2011, at the centre. RESULTS: The mean and median annual CED were 17.2 and 4.9 millisieverts (mSv) per patient-year. The mean and median total CED per patient over the study period were 46.1 and 17.3 mSv, respectively. Twenty-eight and 12% of patients had total CED >50 and 100 mSv, values which are associated with a good or strong evidence of an increased cancer mortality risk, respectively. Computed tomography scanning accounted for 73% of the total CED. The annual CED was significantly higher in incident patients and in patients with ischaemic heart disease and cancer. CONCLUSION: In this institution, multiple testing of kidney transplant patients was common in many patients associated with high cumulative estimated doses of ionizing radiation.

[Human papillomavirus infection and cervical intraepithelial neoplasia in dialyzed patients]. / Infezione da papilloma virus e neoplasia intraepiteliale cervicale in pazienti dializzate: esperienza monocentrica.

Human papillomavirus (HPV) infection is a risk factor for the development of cervical intraepithelial neoplasia (CIN). The incidence of certain cancers such as HPV-associated CIN is higher among dialysis patients than in the general population. In the literature there are few studies on the prevalence of HPV infection among dialyzed women and almost all of these studies concerned women with positive Pap smears. We enrolled 73 hemodialyzed women attending our center from January 2009 to December 2010; 29 denied informed consent and 44 underwent Pap tests and cervical curettage for HPV (mean age 62 ± 15 years). We found HPV positivity in 6 women (prevalence 13.6%). The prevalence of CIN in our sample was also 13.6% (6/44), 83.3% of which HPV related. Since cervical curettage for HPV is a cheap and easy to perform test with high specificity and sensitivity, we believe it is worthwhile including it in the pre-transplant workup of such women to lower the incidence of CIN in dialyzed patients and transplant recipients.

The middle arm arteriovenous fistula is an additional option to expand autogenous hemodialysis access.

PURPOSE: The native arteriovenous fistula is the gold standard for hemodialysis access. Unfortunately, the wrist fistula is often not practical and the upper arm fistula is hindered by several complications. The aim of this study is to assess the safety of the middle-arm fistula as additional native access. METHODS: We reviewed and compared the patency rates at 12, 48, and 60 months of distal, middle, and upper arm fistula performed from January 2003 to December 2008. For diabetic and old patients we compared distal and middle-arm fistulas. RESULTS: Of 273 native access, 149 (54.6%) were distal, 92 (33.7%) middle-arm, and 32 (11.7%) upper fistula. Patency rates were 81%, 58%, and 52% for distal, 85%, 69%, and 69% for middle-arm, and 82%, 46%, and 29% for upper arm fistula (P NS). Patency rates were 92%, 70%, and 54% in middle-arm fistula as first access and 80%, 71%, and 71% in middle-arm fistula as a rescue access (P NS). Among patients > 75 years patency rates were 78%, 62%, and 62% for distal and 87%, 67%, and 67% for middle-arm fistula. Among diabetic subjects patency rates were 81%, 58%, and 58% for middle-arm and 65%, 57%, and 57% for distal fistula at 12, 48, and 60 months (P NS) respectively. CONCLUSIONS: A middle-arm fistula is as safe as a distal fistula among dialyzed patients, even diabetic and elderly. This could be considered a reliable option to expand native accesses.