Feeding a diet contaminated with ochratoxin A for chickens at the maximum level recommended by the EU for poultry feeds (0.1 mg/kg). 1. Effects on growth and slaughter performance, haematological and serum traits.

The European Commission Recommendation 2006/576/EC, suggests that the maximum level of Ochratoxin A (OTA) in poultry feeds should be set at 0.1 mg OTA/kg. Thirty-six one-day-old male Hubburd broiler chickens were divided into two groups, a Control (basal diet) and an Ochratoxin A (basal diet + 0.1 mg OTA/kg) group. The growth and slaughter performance traits were recorded. The liver, spleen, bursa of Fabricius and thymus weights were measured. The erythrocyte and leukocyte numbers were assayed in blood samples, and the heterophils to lymphocytes (H/L) ratio was determined. Alpha-1-acid glycoprotein (AGP), lysozyme, the total protein and the electrophoretic pattern were evaluated in serum samples. Liver enzymes (alanino aminotransferase, ALT and aspartate aminotransferase, AST) and kidney function parameters (uric acid and creatinine) were quantified. The results revealed that feeding a 0.1 mg OTA/kg contaminated diet to chicks caused a decrease in the absolute thymus weight (p < 0.05) and a lower total protein (p < 0.01), albumin (p < 0.01), alpha (p < 0.05), beta (p = 0.001) and gamma (p = 0.001) globulins serum concentration in the Ochratoxin A group. Moreover, the albumin-to-globulin (A/G) ratio of the OTA-treated animals resulted to be higher (p < 0.05). Feeding broiler chickens, a diet contaminated with the maximum level admitted by the European Commission Recommendation (0.1 mg OTA/kg), did not affect the animal performance, slaughter traits, organ weights, haematological parameters, liver enzyme or renal function parameters concentrations but had an overall immunosuppressant effect, with reduction in the thymus weight and of the total serum protein, albumin, alpha, beta and gamma globulins concentration.

[Vascular access in elderly: AVF versus CVC]. / Accesso vascolare nell'anziano: FAV versus CVC.

The characteristics of patients on dialysis have changed significantly in the last years. Aging and comorbidity are the most important aspects of this change. Vascular access problems are frequent in elderly people and contribute to the increased morbidity and mortality. Arteriovenous fistula (AVF) remains the preferred method but may be difficult or unadvisable in older patients because of a short life expectancy, poor vasculature or poor cardiac function. In fact, increasing use of CVC has been reported in recent studies. Psychological and quality of life-related aspects should also be taken into account when scheduling vascular access in older patients: from this point of view CVC may be a good alternative to an aggressive surgical policy. Decreasing CVC-related complications is feasible through the consistent application of basic rules; the center effect may be relevant in this context. However, the use of CVC remains a kind of double-edged sword: even in older people preferring it over AVF is justified only if good results can be guaranteed. The final choice will have to be based on a multidisciplinary approach and careful assessment of resources.

Phenotypic and genotypic risk factors for cardiovascular events in an incident dialysis cohort.

Cardiovascular disease (CVD) remains the major cause of death in patients with end-stage renal disease (ESRD). Traditional risk factors do not explain the high prevalence of CVD in this population, and other non-traditional cardiovascular (CV) risk markers have now been described. Therefore, the potential relationship between CVD and phenotypic and genotypic risk markers was investigated prospectively in incident dialysis patients cohort. The 279 patients (244 on hemodialysis, 35 on peritoneal dialysis) within the Diamant Alpin Dialysis Cohort Study were investigated. Phenotypic and genotypic parameters were determined at dialysis initiation, patients monitored over a 2-year period, and CV events (morbidity and mortality) recorded. Globally, 82 CV events occurred and 26 patients (9.3%) died from CVD, whereas 28 (10%) died from non-CV causes. Previous CV events were strongly predictive of CV events occurrence, whatever patients had had one (hazard ratio (HR) 2, 95% confidence intervals (CI) 1.1-3.5) or more (HR 3.9, 95% CI 2.1-7.1) CV accidents before starting dialysis. Both lipoprotein(a) (HR 1.67, 95% CI 1-2.5) and total plasma homocysteine at cutoff 30 micromol/l (HR 1.7, 95% CI 1.1-2.8) were independent predictors of CV events outcome. In the subgroup of patients with homocysteine < 30 micromol/l, methylenetetrahydrofolate reductase (MTHFR) TT was the sole biological parameter predictive of CV event outcome (HR 2.5, 95% CI 1.1-10, P = 0.03). ESRD patients who enter chronic dialysis with a previous CV event, high total homocysteinemia levels, or MTHFR 677TT genotype must be considered at high risk of incident CV events.

[Clinical and instrumental surveillance of the arteriovenous fistula]. / La sorveglianza clinica e strumentale della fistola arterovenosa.

Stenosis and thrombosis are the most important complications leading to vascular access failure in hemodialysis (HD). Aiming for an early access dysfunction diagnosis and elective repair of the failing access, the DOQI guidelines recommend that all HD patients undergo a program of regular monitoring and surveillance. The K/DOQI 2000 update identifies specific types of evaluation for dialysis accesses. First nephrologists should examine patients by inspecting, ausculting and palpating the access at least every 4-6 weeks when patients are not being dialyzed. In addition, access surveillance should be regularly performed by various techniques, i.e. urea recirculation test, dialysis venous pressure measurement and access blood flow assessment. Recently many methods have been proposed and implemented. Ultrasound dilution is the most commonly used. This technique relies on the change in ultrasound velocity when blood is diluted with a normal saline bolus at a known dialyzer blood flow rate, after the lines have been reversed. Following the use of blood ultrasound dilution, multiple technologies have been implemented for access flow measurement with line reversal, i.e. hematocrit (Hct) dilution, thermodilution, conductivity variation assessment. There are three other methods that do not require line reversal: i.e. transcutaneous access flow (TQA) assessment, glucose pump test (GPT) and the variable flow Doppler. Finally, duplex scanning can provide both the anatomy and blood flow of the access. With a Qa <600 mL/min or <1000 mL/min, but reduced by 25% in 4 months, K/DOQI suggest performing angiography and eventual elective repair.

[Organohalogen contamination of a dialysis-water treatment plant]. / Contaminazione da organo-alogenati di un impianto di trattamento di acqua per dialisi.

On March 2001 the regular quality control test of the water used for dialysis in an urban centre using a reverse osmosis system revealed a high level of organo-halogenated contamination. The compounds implicated were: trichloroethylene (trielene) [M.Wt. 131 D], tetrachloroethylene, trichloromethane (chloroform) [M.Wt. 121 D], chlorodibromomethane. The dialysis unit was closed. Water samples were analysed in duplicate. The table shows the values (in ppm or microgram/l) obtained for chloroform at the given times: March 8th, altered sample; March 12th, confirmation sample; March 16th, after osmosis membranes change; March 22nd, after carbon filtration replacement; March 26th, after softener resins substitution. The AAMI doesn't recommend any value for organo-halogenated compounds in dialysis water. In the past, the European Pharmacopoeia and the Italian Health Ministry released some reference values for tap water, values which were extended to water used for dialysis. The values are 1 ppm as reference value, 30 ppm as maximum accepted value for the sum of all organo-halogenated compounds, and 10 ppm as the recommended value. In conclusion, the problem was solved by progressive replacement of the components of the water treatment system, even though the real cause remained undetermined. No clinical symptom was recorded and no level of chloroform or trielene was detected in patients' sera despite the low molecular weight and low protein binding of the compounds. A strict control of the water quality and a more comprehensive and updated reference guide are needed for better and safer dialysis delivery.

[Spiral x-ray computed tomography in the diagnosis of central venous catheterization complications]. / Contribution de la tomodensitométrie spiralée dans le diagnostic des complications du cathétérisme veineux central.

In this work we report our initial experience on the utilisation of the spiral tomodensitometry in the study of the vascular complications due to the catheterization of the internal jugular vein. We present the results of a systematic search of vascular lesions after removal of an indwelling catheter in a group of 18 patients and describe a few cases of acute complications where the use of TDMS has been very useful in the diagnostic workout. The results confirm the risks associated with the catheterization of the internal jugular vein, showing a frequency of lesions of various degree in about 50% of the cases. Moreover, we discuss some aspects of the thrombotic complications in the patients carrying a central venous catheter and the advantages of the diagnostic application of the spiral tomodensitometry.

Dialock(R)subcutaneous port for hemodialysis: A twelve-month experience in a single center.

Background.The arteriovenous fistula (AVF) is still considered the golden standard form of vascular access for hemodialysis. However, the increasing use of central venous catheters mirrors the growing difficulty in planning an AVF. A totally implantable new device, the Dialock(R)system (Biolink Corporation, Norwell, MA), allowed us to conduct the first Italian experience. Methods.From February 1st 2000 to January 31st 2001, we implanted 21 devices in 12 males and 9 females, median age 66+/-12 years, with a dialysis duration ranging from 0 to 22 years. In 6 cases the Dialock (R)was first choice access, in 5 it replaced a malfunctioning tunneled central venous catheter, and in 10 cases it was the rescue access after previous AVF failures. Results.On average, the device was accessed 3.5 days after implantation. Median duration of use was 142 days (range 29-365), for a global observation period of 118.2 pt-months. Nineteen devices are currently working with-out any problem. One port was removed after 60 days due to thrombosis, and another after 9 months of use due to sepsis. Another patient had a systemic infection with cardiac and vertebral involvement with complete remission after 4 months of antibiotic therapy and salvage of the device. The infection rate was 1.3 per 1000 catheter-days. Prescribed blood flow was achieved in 95.7% of the sessions. Conclusion.Our short-term results confirm the efficacy and reliability of the new device. In order to assess the true indication for implanting Dialock(R), a more prolonged observation period is needed.

GIT (Glucose Infusion Test): polycentric evaluation of a new test for vascular access recirculation.

Introduction. Vascular access recirculation (AR), which is often unacknowledged, remains an important cause of inadequate dialytic dose. The glucose infusion test (GIT) is a new method for detecting and quantifying AR. This paper reports on a polycentric evaluation of the new test and a comparison with the classical Urea-test (UT). Methods. GIT protocol comprises withdrawal from the arterial port (sample A), injection into the venous drip chamber of 1 g glucose in 4 seconds, withdrawal from the arterial port (sample B) continuously from 13 to 17 seconds. Glucose is determined on A and B by a reflectance photometer. If B = A then there is no recirculation. If B exceeds A by at least 20 mg/dl there is recirculation. AR quantification: AR% = (B-A) / 20. GIT was performed on 623 patients from eleven dialysis centers to screen the patients for AR. Subsequently, GIT and Urea-test (UT) were compared in 189 paired tests. The reproducibility of GIT and UT was studied in 28 paired tests performed in sequence. Results. The screening test by GIT was positive in 68 cases (11 %). The majority of positivities was found in central venous catheters (CVC, 27/50 cases, 54 %), whereas only 7 % of artero-venous fistulas (AVF) were positive. In the CVC group, Tesio catheters were more frequently positive compared to Dual Lumen Catheters (64 % vs. 29 %). The comparison GIT - UT showed that results matched in 162 tests (79 negative and 83 positive both by GIT and UT), showing that on the grounds of UT, GIT has high sensitivity and specificity. In 27 tests GIT was positive, but UT negative. This disagreement is due to the different minimal limit of detection, 1 % for GIT and 5% for UT. The reproducibility was greater with GIT than with UT with a lower D% (respectively -0.6 +/- 2.5 and -0.4 +/- 6.1 %, p<0.001) and a lower coefficient of variation (17 vs 33 %). Conclusions. The screening of 623 patients by GIT confirmed that AR in AVF is normally absent, whereas an un-expectedly high frequency of moderate AR in CVC was found. The GIT-UT comparison showed that the new test is simple and immediate, and gives results with higher accuracy, sensitivity and reproducibility than UT.

[Vascular access for chronic hemodialysis: current status and new directions in the Piedmont]. / Accessi vascolari per emodialisi cronica: situazione attuale e nuovi orientamenti in Piemonte.

Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.

HCV viremia in hemodialysis patients: detection by a DNA enzyme immunoassay for amplified HCV sequences.

The aim of this study was the detection of HCV viremia in both anti-HCV antibody positive and negative hemodialysis patients. Sera from 75 patients on extracorporeal blood purification in the same dialysis unit were analyzed. Anti-HCV antibodies were detected using a 2nd-generation ELISA assay and in all positive cases a RIBA 3rd-generation test was performed. HCV-RNA was tested by a reverse transcription-nested polymerase chain reaction (RT-PCR) assay with primers located in the 5' region. PCR products were analyzed by a nonradioactive hybridation assay. The presence of anti-HCV antibodies was detected in 30 (40%) patients by means of ELISA II test; 28 of them were RIBA III positive and two indeterminate. Twenty-four of the 30 HCV Ab ELISA II positive patients (80%) were HCV-RNA positive (23 RIBA III positive and 1 indeterminate). Six anti-HCV Ab ELISA II positive patients tested negative for HCV-RNA (20%); 5 of these patients were also positive for anti-HCV antibodies with a RIBA III test and 1 was indeterminate. None of the anti-HCV negative patients was HCR-RNA positive. In two cases we documented the disappearance of viremia after an acute HCV infection, with the persistence of antibody reactivity. In conclusion, anti-HCV antibody positive hemodialysis patients should be considered as potentially infectious.

[Helicobacter pylori in patients undergoing periodic hemodialysis]. / L'Helicobacter pylori in pazienti sottoposti ad emodialisi periodica.

Forty-nine haemodialyzed patients have been submitted consecutively, under informed consent, to endoscopy with multiple antral gastric mucosa biopsies for Helicobacter pylori (HP) identification, performed by urease, microscopic and cultural tests, as well as histologic examination. Patients have been considered HP negative when negative for all tests; positivity for HP has been correlated with gastritis histologically evaluated according to Whitehead; at endoscopy, blood samples for HP specific IgG, IgA, IgM have been collected; patient's life style concerning smoke, alcohol and drugs as FANS has been investigated as well. HP prevalence in our haemodialyzed patients is 38.8 per cent, similar to general population submitted to endoscopy; a statistically significant correlation between HP and gastritis and specific IgG, but no correlation between HP and age, dialysis duration, IgA, IgM, smoking, alcohol or drugs consumption has been found.

[Dialysis treatments outside the hospital]. / I trattamenti dialitici extra-ospedalieri.

In the early sixties a dramatic lack of hospital dialysis facilities prompted the development of home dialysis programs. The same reasons favoured in Turin, several years later, the start of a home-dialysis program and of the first European self dialysis program in an out-of-hospital setting. In the following years continuous ambulatory peritoneal dialysis was begun. In the last few years we are experiencing a new shortening of in-hospital dialysis facilities; moreover, special attention is devoted to the costs of dialysis treatment, often overlooked in the past. It is likely that self-care and home dialysis will again aid us to solve these problems, as in the past. In this paper we report on the clinical, rehabilitative and socioeconomic results of out-of-hospital dialysis treatments, and on the possible future development of home-hemodialysis and CAPD in Piedmont.

[Informatics support and teledialysis]. / Supporto informatico e teledialisis.

Computer-assisted medical activity is increasing in several fields, with wide perspectives in nephrology and dialysis accounting for the peculiar characteristics of this population such as number, complexity, follow-up length and economic costs. Since 1980 we have been studying a computerized organization of our Region's departments in order to achieve 3 main results: 1) a registry of all patients undergoing dialysis in the area, with a one- a-year complete clinical update; 2) a computerized medical chart, which could gather all the clinical, technical and managerial aspects of the treatment; 3) a teledialysis program, to follow every session in local and remote stations. The first aim has been reached with useful information for the dialytic policy in the area. The second objective is ongoing with straight evidence of easy, speedy procedures, and accurate data collection. The third goal is on a preliminary phase looking at the safety, reliability and precision of the treatments. Informatic procedures seem to be quite advisable in improving as clinical surveillance of the patients, as technical and managerial aspects of dialysis units.

Sodium-lithium countertransport activity in red blood cells of patients with IgA nephropathy.

In this paper we report some results of our studies on patients with immunoglobulin (Ig)A nephropathy regarding (1) the familiar aggregation of erythrocyte sodium-lithium (Na,Li) countertransport; (2) the association of Na,Li countertransport with the presence of arterial hypertension and lipid abnormalities; (3) the correlation between Na,Li countertransport activity and renal functional reserve; and (4) the preliminary results of a longitudinal study. In 13 families of patients with IgA nephropathy, selected because both parents were available, we found a significant correlation between midparent and offspring Na,Li countertransport activity (Spearman's rank correlation = 0.65; P = 0.023), but no husband-wife relationship. In 49 patients, the activity of Na,Li countertransport was significantly higher in erythrocytes from 20 hypertensive patients than from either 29 normotensive patients or from 36 healthy age- and sex-matched normal subjects. Hyperlipidemic patients had an erythrocyte Na,Li countertransport activity significantly higher than normolipidemic patients and controls. In 17 patients a significant inverse correlation was found between the peak variation of creatinine clearance over baseline value after an oral protein load and the erythrocyte Na,Li countertransport activity (Spearman r = 0.54; P = 0.03). In a longitudinal study of 36 patients followed from 12 to 36 months, those showing a progression toward renal failure had an erythrocyte Na,Li countertransport activity higher than median value. The results of our studies show that in patients with IgA nephropathy a high erythrocyte Na,Li countertransport rate, genetically determined, is associated with the presence of arterial hypertension and lipid abnormalities, and perhaps with a less favorable disease outcome.

[Changes in cellular ion transport and arterial pressure in renal transplant recipients undergoing cyclosporin treatment]. / Alterazioni del trasporto ionico cellulare e pressione arteriosa nei portatori di trapianto renale in trattamento con ciclosporina.

Arterial hypertension is a common side effect of cyclosporine A (CyA). Aim of the study was to evaluate the activity of erythrocyte (RBC) Na transport in two groups of patients with a well functioning renal graft (Crs less than 1.7 mg/dl) treated by prednisone+azathioprine (10 pts), or prednisone+CyA (21 pts), in relationship with blood pressure status. Twenty-one age matched healthy subjects were studied as a control group. Na,K pump and Na,K cotransport were significantly lower in CyA than in AZA patients (2,184 +/- 106 vs 3,089 +/- 162 and 58 +/- 8 vs 187 +/- 28 mumol/l RBC/h: p less than 0.01), without differences between normotensive and hypertensive patients. Na,K pump efflux in normal subjects was 2334 +/- 66 mumol/l RBC/h (p less than 0.01 vs AZA), NA,K cotransport was 205 +/- 18 mumol/l RBC/h (p less than 0.01 vs CyA). Significant correlations were found between RBC Na,K pump activity and trough plasma CyA levels (p less than 0.02) and between systolic pressure and plasma creatinine in CyA patients (p less than 0.01). Trough plasma CyA levels were higher in hypertensive than in normotensive CyA patients (64 +/- 5 vs 46 +/- 4 ng/ml; p less than 0.01).

[Two years of experience and 119 peritoneal dialysis catheters placed with peritoneoscopy control and Y-TEC system]. / Due anni di esperienza e 119 cateteri per dialisi peritoneale posizionati con controllo peritoneoscopico e sistema Y-TEC.

In this work we report our 24 months experience in the placement of 119 peritoneal catheters in 105 patients (59 males, 46 females, mean age 60.1 years; range 24-90) using the peritoneoscopic insertion technique. After catheter implantation a dialysis solution leak is encountered in 7.5% of cases, tunnel infection in 4 cases (3.3%) and exit site infection in 12.5% of the catheters. Placement by endoscopic control is considered as a technique able to avoid catheter migration; in our series we reported this complication in 15 cases (12.5%). The easy access to the peritoneal cavity and the atraumatic insertion of the catheter obtained with the Y-TEC procedure reduced the hospitalization period from 25 to 5 days on average. In our experience actuarial survival of catheters is 82.5% at 24 months.

[Effects of saline infusion on the activity of erythrocyte sodium-potassium pump in normal subjects and in patients with essential hypertension]. / Effetti dell'infusione salina sull'attività della pompa Na,K eritrocitaria in soggetti normali e in pazienti con ipertensione essenziale.

The effects of a 2 litre isotonic saline infusion on erythrocyte Na,K pump activity and urinary sodium excretion (UNaV) were evaluated in 20 patients with essential hypertension and 15 normotensive subjects. The effect of preincubation of normal erythrocytes in plasma from hypertensive patients on erythrocyte Na,K pump was also studied. Before saline infusion no significant differences were found between normotensive and hypertensive subjects in the mean values of intracellular sodium and potassium concentration, ouabain-sensitive Na efflux in erythrocytes and urinary sodium excretion. Erythrocyte Na,K pump activity decreased significantly (p less than 0.01) after saline infusion in both groups of subjects. The reduction was significantly lower in hypertensives than in normotensive. delta UNaV was significantly higher in hypertensive patients than in normotensive subjects (25 +/- 4 vs 14 +/- 2 mmol/h; p = 0.04). Only in normal subjects a significant correlation was found between the difference in Na,K pump activity pre and post saline infusion and delta UNaV (r = 0.52; p less than 0.05). Plasma from hypertensive patients obtained before saline infusion significantly (p less than 0.01) inhibited Na,K pump of erythrocytes from normal subjects; plasma taken after saline infusion produced a marked increase of this inhibition, significantly (p less than 0.01) higher than serum taken before the infusion.

[Peritoneal complications of continuous ambulatory peritoneal dialysis]. / La complicanza peritonitica in dialisi peritoneale ambulatoriale continua (CAPD).

Aim of this work is an analysis of the clinical and microbiological aspects in 205 peritonitis episodes occurred in 156 patients admitted on peritoneal dialysis from January 1980 to December 1989. The evaluation of causative organisms shows a high prevalence of Gram+ organisms (60% of cases), while Gram- organisms are responsible for 16% of peritonitis episodes and fungi for 4%. No cultural growth was observed in 13% of the cases, while more than one organism occurred in 7%. Peritonitis incidence decreased from one episode every 3.9 patient months during 1980-81 to one every 33.6 patient months during 1988-89. This improvement is especially related to the employment of Y-set connection system and to the sterilization of connection lines by amuchina. From 1984 Y-set was used in each of the new patients admitted on CAPD. After its employment peritonitis incidence decreased from one episode every 6.2 patient months to one every 29 patient months. In our experience vancomycin i.v. proved to be effective and well tolerated. In no case a persistence of infectious disease was observed and no catheter was removed.

[Atherosclerotic vascular nephropathy. Description of 2 clinical cases and review of the literature]. / La nefropatia vascolare aterosclerotica. Descrizione di due casi clinici e rassegna della letteratura.

Atheromatous nephropathy, due to a reduction of arterial blood flow caused by stenosis or thrombosis of renal arteries, is now recognized as an important cause of chronic renal failure in the elderly. It has been shown that renal revascularization may allow a recovery of renal function up to the withdrawal of dialytic treatment. Digital arteriography is the preferred diagnostic method, but doppler scan and renal scintigraphy after administration of captopril may also prove useful, specially in the follow-up of the patients. Therapeutic means include percutaneous transluminal angioplasty and surgical revascularization; both treatments may improve or stabilize renal function. Surgery may allow better results in the long term, but is loaded by a significant morbidity. Our experience confirms the possibility to obtain a significant long term improvement of renal function after bilateral surgical revascularization.