[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.

[Acute kidney failure caused by cholesterol atheroembolism]. / L'insufficienza renale acuta da ateroembolismo colesterinico.

BACKGROUND: To describe the clinical aspects of renal failure due to cholesterol atheroembolism. METHODS: An hospital based observational study on renal failure due to cholesterol atheroembolism was carried out. Twenty-two cases (19 males, mean age 68 yrs, range 53-83 yrs) were identified from January 1992 to September 1998. RESULTS: Clinical symptoms were acute or rapidly progressive renal failure with blue toe and/or skin livedo reticularis in 13/22 cases (59%) and indolent progressive renal failure in 7/22 cases (32%). In 6/22 cases (27%) an abdominal organ involvement was evident; two (9%) had retinal cholesterol emboli, two (9%) peripheral and two (9%) central nervous system impairment. In 7 patients (32%) the cholesterol atheroembolism occurred spontaneously, while in 15 (68%) it followed invasive or interventional radiology (8 cases, 36%); cardiac or vascular surgery (4 cases, 18%); thrombolytic or anticoagulant therapy (3 cases, 14%). The time interval between the procedure at risk and the onset of symptoms or signs of cholesterol atheroembolism ranged between few hours to 60 days. Eleven patients (50%) required dialysis, which was then withheld in 4 cases (36%), owing to partial functional recovery after a median time of 30 days, ranging from 10 to 690 days. Median follow-up was 2.5 months (ranging from 2 days to 68 months), and eleven patients (50%) deceased. CONCLUSIONS: Cholesterol atheroembolism is a cause of renal failure associated with high mortality rates; its prevention needs the skill of all physicians involved in the care of patients with severe atherosclerosis.

[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.

Are serum albumin and cholesterol reliable outcome markers in elderly dialysis patients?

Albumin and cholesterol are considered reliable outcome markers in dialysis patients; their influence, however, may also be related to non-independent factors, such as age and presence of co-morbid conditions. The aim of the study was an analysis of four outcome markers, assessed at start of dialysis: age, high risk conditions, cholesterol and albumin levels. Data were obtained from the Piedmont Dialysis and Transplantation Registry (northern Italy, about 4,400,000 inhabitants, 21 dialysis centres, open acceptance since mid-1970s, 5661 patients on file at 31 December 1992). Prevalence of albumin and cholesterol in the normal range increases with age; in each age group prevalence in the range is higher in patients at high risk. However, influence of these biochemical parameters is evident also in no-risk cohorts, thus identifying a subgroup with poorer prognosis also in the population without any identified classic risk factor. The influence of albumin, more evident in the population studied compared with cholesterol, is reflected by impaired survival of low-albumin patients (age > or = 65 high risk at 1 year: 60.7% vs 76.6%, P = 0.0052; age > or = 65 non-high risk, at 1 year: 76.5% vs 90.7%, P = 0.0001). In conclusion, albumin and cholesterol, assessed at start of dialysis, are reliable outcome markers even in elderly patients, identifying, in this high mortality cohort, a subgroup with poorer prognosis. If and how their effect may be reversed by dialysis therapy remains to be assessed.

[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.

[Surgical interventions in dialysis patients in Piedmont: data from the Regional Registry. Working Group of the Piedmont Registry of Dialysis and Transplantation]. / Interventi chirurgici nei pazienti in dialisi in Piemonte: dati dal Registro Regionale (RPDT). Gruppo di lavoro dell'RPDT.

In this work surgical events in a large population of chronic dialysis patients are analysed. Data are obtained from the Regional (Piedmont) Registry of Dialysis and Transplantation (RPDT), that has collected information since 1981 about all chronic dialysis patients in the Region. Since 1984, causes of admission to-hospital are registered. Surgical causes of hospitalization, for purposes not related to uremia, were 538 (20% of all surgical admissions). In patients younger than 65 years, these hospitalizations account for about 6% of the cases, whereas in patients older than 65 they are less than 5%. As expected, a higher number of surgical operations is observed in diabetics, while on the contrary the lowest is performed in nephroangiosclerosis patients. Cardiovascular and bowel diseases represent almost 50% of all surgical needs. Postoperative mortality was 5.8% within 45 days from admission. Cardiac and infectious diseases and cachexia represent the more frequent causes of death. In 27 out of 28 cases at least one high risk condition was present.

[The value of albumin and cholesterol blood levels as indicators of the risk of death in dialysis. Working Group of the Piedmont Registry of Dialysis and Transplantation]. / Il valore dei livelli di albuminemia e colesterolemia come indicatori del rischio di morte in dialisi. Gruppo di lavoro dell'RPDT.

In recent years, the availability of large epidemiological series allowed identification of biochemical outcome markers in the dialysis population. Interest towards albumin and cholesterol levels is motivated by their easy availability and by the presence of a strong short-term effect on mortality and morbidity. The aim of the study was an analysis of the relationship between albumin and cholesterol levels at start of dialysis and mortality (gross mortality and Kaplan Meier survival curves). Data were obtained from the Piedmont Regional Registry of Dialysis and Transplantation (Northern Italy Region, about 4,400,000 inhab, 20 Dialysis Centers, open acceptance since mid '70, yearly information on 100% of patients) in the period 1981-1990 (4734 patients on file). Only non diabetic patients with follow-up > = 1 month, who started treatment in the Region, were selected. Patients with renal function recovery were excluded. Albumin levels were dichotomized at 3.5 g/dl. Cholesterol was stratified into 3 levels (< 150, 150-250, > or = 300 mg/dl). The choice of dividing the study into 2 periods (1980-1985 vs 1986-1990) is due to the fact that 1984 has been the year of switch from acetate to bicarbonate dialysis. Prevalence of albumin and cholesterol under the normal range (22% and 15%) is low and rises with age and presence of high risk conditions. A a good correlation with the risk of death of these biochemical markers (stronger for albumin at least in the short term) was observed. No correlations are found with risk of death and elevated cholesterol levels (low number of cases).(ABSTRACT TRUNCATED AT 250 WORDS)

[Automated peritoneal dialysis (APD). Experience in 42 patients]. / La dialisi peritoneale automatizzata (APD). Esperienza in 42 pazienti.

Automated peritoneal dialysis (APD) is currently considered as one of the most attractive home treatments for uremic patients. However, relevant costs and the presence of a dialysis machine prevent a wider diffusion of this technique. In this work we discuss the results obtained in 42 patients (12 females, 30 males) treated by two dialysis units of the Piedmont Region. Patients' characteristics. Eighty-three percent of the females and 66.5% of the males are under 65 years of age; glomerulo-nephritis and nephroangiosclerosis account for the most frequent renal diseases (28.5 each); a high risk condition is recorded in 52.5% of cases. Twenty-two patients were transferred to APD from CAPD (patient's request in 59% of cases, clinical problems in the remaining). RESULTS. Forty-five percent of cases are working full or part-time, 12% are not caring for self. Peritonitis rate accounts for 1 episode every 42 patient-months. Biochemical control is satisfactorily achieved (mean values: urea 137.8 mg/dl, creatinine 11 mg/dl, calcium 10.2 mg/dl, phosphate 5.7 mg/dl, albumin 4.3 g/dl, cholesterol 234 mg/dl, triglycerides 195 mg/dl). Technical assistance was requested on average once every 16 months of treatment. CONCLUSION. Negative drawbacks of APD, mainly related to elevated costs and technical complexity, are fully counterbalanced by satisfactory social and clinical rehabilitation, wider indications to peritoneal dialysis with respect to CAPD, lower rates of peritonitis and limited technical needs.

Death in conditions of cachexia: the price for the dialysis treatment of the elderly?

Death in conditions of cachexia is increasing in potential dialysis patients, as treated cohorts are aging, the mean age of new patients increased and access to treatment is unlimited. The present study analyzes the clinical features of 417 deaths in conditions of cachexia recorded in 1981 to 1990 in the Dialysis and Transplantation Registry of a northern Italian region, Piedmont (about 4,400,000 inhabitants, 20 dialysis centers; 4,734 patients on file at December 31, 1990; yearly information on 100% of the cases). Death in conditions of cachexia increased from 105 cases in the first four years taken into account (1981 to 1984), to 107 in the last two years (1989 to 1990). Prevalence is higher in the elderly (85% of the death over age 60). Most patients (90.5%) were at high clinical risk. To assess whether the frequency of this diagnosis reflected the wide acceptance of elderly patients for dialysis and was a marked of vascular disease, a specific inquiry was conducted about 107 cachectic deaths recorded from 1989 to 1990: 82.5% of the patients had diffused vascular disease, 11.5% were already cachectic when dialysis was initiated, and 66% were in cachexia at least six months before death. Since mean age of patients dying in condition of cachexia increased from 68.8 in the period of 1981 to 1984 to 70.3 years in 1989 to 1990, and mean time on dialysis from 2.8 years in 1981 to 1984 to 70.3 years in 1989 to 1990, the higher prevalence is not likely to be due to lack of care of elderly patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetic patients on dialysis: a changing picture.

Prevalence of diabetic patients on dialysis is often considered a marker of overall acceptance rate for dialysis; however, even when acceptance policy is open, incidence of diabetic patients varies widely. Epidemiological differences of diabetes incidence all over the world partly explain the discrepancies. Incidence of diabetic patients accepted for dialysis (1981 to 82: 6 p.m.p.; 1989 to 90: 11.5 p.m.p.) differs according to age and sex in the setting analyzed (Piedmont, Northern Italian region, about 4,400,000 inhabitants, 20 dialysis centers, open acceptance since the mid-70s, yearly information on 100% of patients, gathered by a Dialysis and Transplantation Registry). Patterns changed remarkably during the 10 years considered (1981 to 90). Incidence was higher in males (10.4 p.m.p. in the period 1981 to 90), with a peak at ages 60 to 69. Incidence remained relatively stable in the younger patients, but increased in the elderly, mainly in males, rising from 6.23 in 1981 to 82 to 12.88 p.m.p. in 1989 to 90 (males, all ages). In conclusion, the demographic characteristics of diabetic patients with ESRD accepted for dialysis is changing. The stability of incidence of younger patients reassures about the open acceptance policy, at least in these ages. The increase in the elderly probably reflects the longer lifespan of diabetic patients in the overall population. The possibility of a hidden preselection must be further assessed. Future provisions of dialysis needs must take into account the trend towards an increase of this high risk, elderly population.

[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.

[Effects of erythropoietin on the cardiovascular system and the intradialytic hemodynamic behavior]. / Effetti dell'eritropoietina sul sistema cardiovascolare e sul comportamento emodinamico intradialitico.

The aim of the study was to evaluate, before and after hemodialysis (HD), the effects of partial correction of anemia with erythropoietin on: cardiac index (CI), stroke index (SI), heart rate (HR), ventricular ejection index (EVI), mean arterial pressure (PAM) and systemic vascular resistance index (SVRI). Cardiac parameters were gathered by means of transthoracic bioimpedance (BoMed). Twelve patients (6 M, 6 F) aged 50.6 +/- 5 years, on HD for 92.8 +/- 15.9 months, were studied twice (basal, end of follow-up). Before rHuEPO therapy, 6 patients had a "pathologic" cardiac response to HD (defined as an increase of CI despite the reduction of pre-load). After rHuEPO, 5 out of 6 patients with a "pathologic" response reverted to a "normal" response, and 1 hypertensive patient from a "normal" to a "pathologic" response. The EVI, CI and SI of patients with "pathological" response significantly improved after rHuEPO as compared with pre rHuEPO values (EVI 1.36 +/- 0.14 vs 1.07 +/- 0.08, p = 0.023; CI 3.18 +/- 0.24 vs 1.78 +/- 0.27, p less than 0.01; SI 43 +/- 3.7 vs 24 +/- 3.8, p less than 0.01). In conclusion, partial correction of anemia with rHuEPO induces an improvement of myocardial performance, without significant hemodynamic adverse effects. Our results suggest also that anemia could play a significant role in the pathogenesis of myocardial disfunction in HD patients.