[The dawn of Parma's nefrological school as told by one of its students].

This paper, written by Professor Rosario Maiorca, describes the everyday professional life in the institutes of Clinica Medica and subsequently of Patologia Medica at Parma University in the second half of the fifties and in the first years of the sixties of the past century. Those institutes and that period, which have been very important for the birth of Nephrology in Italy, have already been described, from the historical standpoint, in an Italian monograph on the history of our specialty for the period 1957-2007. The present paper adds to that chapter an insight of "real life", with a lively description of the wide and passionate clinical and scientific activities of the young doctors in training and of the personality, greatly stimulating and altruistic, of their "Masters".

Access site-related infection in dialysis: the AStRID project: a multicenter prospective Italian study.

A multicenter prospective study has been planned, in a large sample of Italian end-stage renal disease (ESRD) patients, aiming to assess the vascular access (VA) site-related infection rates and to identify variables associated with them. All ESRD patients undergoing chronic hemodialysis (HD) in the participating centers will be enrolled in the study. Participating centers were selected on a voluntary basis. Patients will be enrolled within an 18-month recruitment period. Primary study end points are the overall incidence rate of VA-related infections in ESRD patients on chronic HD (defined as infection episodes/100 patient-months), and the incidence rate of different types of VA-related infections (exit site, tunnel and bacteraemia/sepsis). All VA types in use will be evaluated: fistula, graft, tunneled (permanent) central venous catheter (CVC) and temporary CVC.

Inter-dialytic variations in blood volume and total body water in uraemic patients treated by dialysis.

BACKGROUND: An optimal balance of sodium and water is one of the most important goals of haemodialysis (HD) therapy. However, while inter-dialytic variations in blood volume (BV) have been well described, very little is known about the dynamics of fluid accumulation and distribution in body compartments during the inter-dialysis period. METHODS: We studied inter-dialysis variations in BV, measured as percent variation of plasma haemoglobin (Hb) concentrations (% triangle up BV) and percent variation of total body water (% triangle up TBW), in 24 uraemic patients treated by standard bicarbonate dialysis. These parameters were determined at the end of the last weekly dialysis (T0), after 24 h (T1), 48 h (T2), and at the beginning of the following dialysis session (T3). At each time point we measured Hb, haematocrit (Hct), serum albumin (sAlb), plasma sodium (Na), plasma potassium (K), blood urea nitrogen (BUN), plasma osmolality (Osm), body weight (BW), systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR). All patients were clinically stable and had no evidence of acute blood loss in the 3 weeks before the study. RESULTS: During the inter-dialysis period, there were increases in BUN, K and Osm, but Na did not change. SBP and DBP also did not change. HR tended to decrease, and showed a significant reduction between T0 and T3. TBW increased in a linear fashion whereas BV increased exponentially, showing a slow rise during the first 24 h followed by a greater increase in the following time intervals. This was confirmed by concomitant but opposite percent variations in Hct and sAlb concentrations. CONCLUSIONS: Despite the limitations of the current methodology, our data show that the increase in TBW is redistributed during the long inter-dialysis period and this may prevent the effects of a too premature expansion of the intra-vascular compartment. This is especially evident during the first 24 h after HD, during which % triangle up BV is lowest, indicating a preferential distribution of the fluid load towards the extra-vascular space. During the following time intervals, the extra-vascular compartment refills in conjunction with an exponential expansion of BV that reaches its maximum in the last 24 h before HD.

Epoetin requirement does not depend on dialysis dose when Kt/N > 1.33 in patients on regular dialysis treatment with cellulosic membranes and adequate iron stores.

BACKGROUND: An inverse correlation between Kt/V and epoetin requirement has recently been demonstrated in stable hemodialysis (HD) patients with adequate iron stores, dialyzed with cellulosic membranes. However, there is no evidence as to whether or not this effect continues for Kt/V even in the adequate or higher range. METHODS: We investigated the relationship between Kt/V and the weekly epoetin dose in 85 stable HD patients (age 63 +/- 16 years) treated with bicarbonate HD and unsubstituted cellulose membranes for 6-338 months (median: 70 months). INCLUSION CRITERIA: HD for at least 6 months, subcutaneous rHuEPO for at least 4 months, transferrin saturation (TSAT) > or = 20%, serum ferritin > or = 100 ng/mL, hemoglobin (Hb) level targeted to approximately equal to 12 g/dL for at least 3 months. EXCLUSION CRITERIA: HBsAg and HIV positivity; need for blood transfusions or evidence of blood loss in the 3 months before the study, acute and chronic infections. To evaluate the effect of dialysis adequacy on the epoetin requirement, we also performed the same analysis after dividing of the patients according to Kt/V. Hematocrit (Hct) and Hb levels were evaluated weekly for 3 weeks; TSAT, serum ferritin, Kt/V, PCRn, serum albumin (sAlb), and weekly epoetin dose were evaluated at the end of observation. No change in dialysis or therapy prescription was made during the study. RESULTS: The results for all the patients were: Hct 36 +/- 2 %, Hb 12 +/- 0.7 g/dL, TSAT 28 +/- 7%, serum ferritin 234 +/- 171 ng/mL, sAlb 4.2 +/- 0.4 g/dL, Kt/V 1.33 +/- 0.17, PCRn 1.15 +/- 0.28 g/Kg/day, weekly epoetin dose 117 +/- 74 U/Kg. There was no correlation between Hb and Kt/V, whereas there was an inverse correlation between the reciprocal of the weekly epoetin dose and Kt/V (r = -0.448, p = 0.0001). Further regression line analysis showed a break-point for Kt/V at the level of 1.33. In the 52 patients with Kt/V < 1.33, the correlation was confirmed between epoetin and Kt/V (r = - 0.563, p = 0.0001), while in the 33 patients with Kt/V > or = 1.33, there was no correlation between epoetin dose and Kt/V (r = 0.021, p = NS). In these patients, multiple regression analysis, with the weekly epoetin dose as a dependent variable, confirmed Kt/V as a non-significant factor. CONCLUSIONS: In iron-replete HD patients on cellulosic membranes and stabilized epoetin therapy, inadequate dialysis was associated with higher epoetin requirement, but for Kt/V values > or = 1.33, there was no further effect on epoetin responsiveness.

Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study.

Atheroembolic renal disease (AERD) is part of a multisystemic disease accompanied by high cardiovascular comorbidity and mortality. Interrelationships between traditional risk factors for atherosclerosis, vascular comorbidities, precipitating factors, and markers of clinical severity of the disease in determining outcome remain poorly understood. Patients with AERD presenting to a single center between 1996 and 2002 were followed-up with prospective collection of clinical and biochemical data. The major outcomes included end-stage renal disease (ESRD) and death. Ninety-five patients were identified (81 male). AERD was iatrogenic in 87%. Mean age was 71.4 yr. Twenty-three patients (24%) developed ESRD; 36 patients (37.9%) died. Cox regression analysis showed that significant independent predictors of ESRD were long-standing hypertension (hazard ratio [HR] = 1.1; P < 0.001) and preexisting chronic renal impairment (HR = 2.12; P = 0.02); use of statins was independently associated with decreased risk of ESRD (HR = 0.02; P = 0.003). Age (HR = 1.09; P = 0.009), diabetes (HR = 2.55; P = 0.034), and ESRD (HR = 2.21; P = 0.029) were independent risk factors for patient mortality; male gender was independently associated with decreased risk of death (HR = 0.27; P = 0.007). Cardiovascular comorbidities, precipitating factors, and clinical severity of AERD had no prognostic impact on renal and patient survival. It is concluded that AERD has a strong clinical impact on patient and renal survival. The study clearly shows the importance of preexisting chronic renal impairment in determining both renal and patient outcome, this latter being mediated by the development of ESRD. The protective effect of statins on the development of ESRD should be evaluated in a prospective study.

Predialysis versus postdialysis hematocrit evaluation during erythropoietin therapy.

American guidelines for the management of renal anemia by recombinant human erythropoietin (rHuEPO) recommend collecting a predialysis blood sample to evaluate hemoglobin (Hb) and hematocrit (Hct) levels in hemodialysis patients. Although a predialysis blood sample is appropriate for evaluating when to start rHuEPO treatment, the same sample would not be appropriate for evaluating the target Hb/Hct to be maintained, particularly when normal or near-normal values are pursued. We measured the degree of intradialytic and extradialytic variation of Hb, Hct, and body weight in 68 stable hemodialysis patients on maintenance subcutaneous rHuEPO treatment. Hb and Hct concentrations were determined before and after dialysis. In 16 patients, Hb and Hct concentrations also were assessed 24 hours after the end of dialysis. Predialysis versus postdialysis Hb and Hct concentrations for all patients were 10.5 +/- 1.3 g/dL versus 11.5 +/- 1.3 g/dL (P < 0.0001) and 32 +/- 4% versus 35 +/- 4% (P < 0.0001). The intradialytic percent variation (%Delta) of Hct and body weight were 10 +/- 6% and -6.3 +/- 3.5%. There was a close inverse correlation between %Delta of Hct and Hb and %Delta of body weight (P < 0.0001). In patients with body weight losses 2.5 kg or more per session, the mean %Delta of Hct was 12 +/- 7%. In the 16 patients studied 24 hours after the end of the dialysis session, Hct and Hb values remained significantly higher compared with the predialysis levels (P < 0.001), suggesting a slow reequilibration of the intravascular volume in the first 24 hours after hemodialysis. For these reasons, predialysis samples for monitoring the target Hb and Hct levels in patients treated by rHuEPO should be considered with caution.