[The treatment of osteodystrophy in dialyzed uremic patients: results of the first Sardinian audit]. / Il trattamento dell'osteodistrofia nei pazienti uremici in dialisi: risultati del primo Audit sardo.

BACKGROUND: Hyperphosphatemia in the uremic patient undergoing dialysis causes and makes the secondary hyperpharatyroidism progress. Nowadays it has a very important role in predicting mortality. The aim of the study was to assess by "Audit" to analyse adequacy of the Sardinian dialytic patients with reference to the optimal objective of the national and international guidelines. PATIENTS AND METHODS: The questionnaire of the audit was composed of 11 questions about the percentage distribution of: calcium in the dialysate, values of phosphoremia), Ca x P product, patients treated with vitamin D taking one or more phosphate binders, average dose, spKt/V > or = 1.2, serum aluminium, parathiroidectomy. RESULTS: We examined 1274 dialysis patients (93% on hemodialysis and 7% in CAPD) in 26 dialytic centers in our region (age 63.8 anni +/- 32.4; dialytic age 5.15 +/- 5.06. Phosphorus ranges (mg/dL) P < 5.5: 61.3 +/- 23%; between 5.5 e 6.5: 28.2 +/- 17.7%; and P > 6.5: 10.4 +/- 7.7%; Ca x P (<60): 77.8% +/- 16.6%; between 60-70: 16.8 +/- 13.4%; > 70: 4.99 +/- 4.7%. The more prescribed dialysate calcium was 1.5 mmol/L in HD (58.8%) HF (60.6%), HDF (51.6%) and CAPD (5.6%). PTH levels were: 31.1% (<120); 29.5% (120-250); 21.1% (250-450); 8% (450-600); 10.3% (>600). Patients on vitamin D: os daily 23.04 +/- 28%; post-dialysis boluses: os 32.6 +/- 28, i.v. 10.6 +/- 9%; no therapy 32.7 +/- 22.7%. The percentage use of phosphorus binders: 48.5% calcium carbonate (2.9 g/d); 7.12% calcium acetate (1.34 g/d); 13.5% sevelamer (2.79 g/d); 10% total aluminium based (0.62 g/d). The aluminium is dosed in 11/26 dialysis units (32.3% of the population); 2.3% +/- 0.9% of patients having Aluminium > 30 mcg/L. The dialytic patients have a Kt/V > or = 1.2: 80.1 +/- 19%. Parathyroidectomy incidences 1.8%. CONCLUSIONS: The data show good control of the average phosporous, there is a worrying percentage of patients with PTH values compatible with hypodynamic bone condition, lower and therefore safer calcium levels in the dialysate, poor aluminium control and low incidence of parathyroidectomy. In our experience the audit is a good way to verify and to correct the therapeutic choice in uremic osteodistrophy.

[Are convective treatments equivalent to the traditional ones? The Hemo Study and beyond (review)]. / Le terapie convettive equivalgono a quelle tradizionali? Lo studio Hemo ed oltre.

Dialysis treatments have allowed 'terminal patients' to live for years and years. However, life expectancy and quality are still consistently reduced in renal dialysis patients. Consequently, all efforts to device alternative treatments to the conventional ones are highly justified. Recently, the Hemo Study showed that neither the use of high flux membranes, nor the increase of the dialysis dose above the conventional, were capable to reduce significantly patient's mortality and morbidity, although 8% reduction of the risk of death was seen in patients treated with high flux vs. patients treated with low-flux dialysis. A relevant question is if convective treatments may offer an overprotection from morbidity and mortality, in comparison with low flux and high flux treatments. Data from the Registro Lombardo di Nefrologia e Trapianto published in 2000 showed a trend toward a better survival (RR= 90) and a significantly better protection from tunnel carpal syndrome (RR= 0.58; p= 0.03) in patients treated with convective treatments (hemofiltration and/or hemodiafiltration) vs. patients treated with diffusive dialysis. Except than a better cardiovascular stability observed on hemofiltration and an higher beta2-microglobuline clearance given by online hemofiltration and hemodiafiltration, evident clinical benefits of convective treatments, over the conventional high flux treatments, are not yet clearly demonstrated. Notwithstanding that, online convective treatments, that are performed with high flux compatible membranes and high technology machines, producing high quality water, offer at the moment the best bases for the improvement of clinical results of dialysis, especially in some category of patients.

[Hyperparathyroidism resulting from chronic renal insufficiency. Diagnosis and therapy]. / Iperparatiroidismo secondario ad insufficienza renale cronica. Diagnosi e terapia.

Twenty-seven patients, eighteen females and nine males, with chronic renal failure and secondary hyperparathyroidism, were treated by subtotal parathyroidectomy. Bone pain, in 24 patients, hypercalcemia in 2 and severe pruritus in 1 were the main indications to surgery. Result evaluation was possible in twenty four patients. Bone pain disappeared or was reduced in 20/22 patients. Serum alkaline phosphatase and PTH returned to normal in 21/24 patients. There patients had persistent hyperparathyroidism because of inadequate surgical exploration. Another group of seven patients with secondary hyperparathyroidism recalcitant to medical therapy or relapsing after subtotal parathyroidectomy was treated with calcitriol ev. After nine months of follow-up PTH and alkaline phosphatase serum levels were reduced to normal value in all patients.

[Psoriatic arthritis: considerations on recent studies: serum beta 2 microglobulin and circulating T-gamma lymphocytes]. / Artrite psoriasica: considerazioni su recenti acquisizioni: la beta 2 microglobulina sierica e i linfociti T gamma circolanti.

The results of two recent studies of our group have been reported. They regard two immunological parameters of psoriatic arthritis: the proportions of T gamma lymphocytes in peripheral blood and the beta 2 microglobulin in the serum. The data obtained in psoriatic arthritis patients have been compared to those found in normal controls and in rheumatoid arthritis patients. T gamma mean values in psoriatic arthritis were significantly lower than those present in healthy subjects and in rheumatoid patients. These last patients showed beta 2 microglobulin mean values significantly higher than those observed in normal controls and in psoriatic arthritis patients. Conversely, the mean of beta 2 microglobulin levels in psoriatic arthritis has been found to be similar to that observed in normal controls, but a superimposition in the range of individual values of these two groups with the concentrations determined in rheumatoid subjects has been found. These results seem to be of interest in relation to the immunopathogenetic mechanism of psoriatic arthritis, but are of little help in the clinical differentiation of the two rheumatological affections considered.

Peripheral blood T lymphocyte subpopulations defined by monoclonal antibodies in rheumatoid arthritis: distribution in patients untreated and treated by oral gold therapy.

The distribution of T lymphocyte subsets was determined in peripheral blood (PB) of two groups of patients with rheumatoid arthritis by using monoclonal antibodies (OKT). In untreated patients the percentage of OKT4+ cells (helper/inducer) was found to be significantly increased as compared to healthy controls. In patients receiving oral gold therapy a similar increase in OKT4+ cells was confirmed; furthermore, these patients showed a significant decrease in OKT8+ cell population (cytotoxic/suppressor) compared to untreated patients and to normal controls. A small numerical superimposition of values of OKT4+ and OKT8+ lymphocytes was observed in untreated but not in treated patients.

T gamma lymphocytes of peripheral blood and synovial fluid in rheumatoid arthritis: quantitative determination and qualitative analysis.

The distribution of T gamma lymphocytes in the peripheral blood of one group of rheumatoid patients and in the synovial fluid in a second group was determined. The results were compared to those found for peripheral blood (PB) lymphocytes of normal subjects and for synovial fluid lymphocytes of osteoarthrosis and meniscitis patients. Besides recording percentage and absolute number, we also used cytofluorographic analysis to determine individual capacity of PB T gamma cells to bind heat-aggregated IgG (agg-IgG). The following results were found: 1) there is no significant difference between the percentage and absolute number of PB T gamma lymphocytes of rheumatoid arthritis (RA) patients and those of controls, 2) individual RA PB T gamma cells had a greater number and/or avidity of Fc receptor for IgG than those cells of controls, and 3) the percentage of RA T gamma lymphocytes in synovial fluid, revealed by IgG-EA ox rosetting, is significantly lower than that found in control patients. The factors that may determine a similar lymphocyte picture in RA are discussed.

Characterization of human T lymphocyte subpopulations (TG and T non G): cytologic examination and cytographic analysis.

Two T lymphocyte subpopulations were separated with an immunological method. In fact recently two T cell subsets with receptors for the Fc of IgM (TM) and of IgG (TG) respectively have been described. We have specifically separated TG and T non G lymphocytes by the rosetting technique. Cytological examination was performed on the two cell fractions: the results are in agreement with that already reported. Cytographic analysis was also carried out confirming the cytologic results. The possible practical implications of these acquisitions and those already applied are discussed.