Quality of life of hemodialysis patients in Central and Southern Italy: cross-sectional comparison between Hemodiafiltration with endogenous reinfusion (HFR) and Bicarbonate Hemodialysis.

INTRODUCTION: in hemodialysis (HD) patients, poor health-related quality of life (HR-QoL) is prevalent and associated with adverse outcomes. HR-QoL is strictly linked to nutritional status of HD patients. Hemodiafiltration with endogenous reinfusion (HFR) is an alternative dialysis technique that combines diffusion, convection and absorption. It reduces burden of inflammation and malnutrition and this effect may cause beneficial effect on HR-QoL. However no data on HR-QoL in HFR is currently available. METHODS: we designed a cross-sectional multicentre study in order to compare the HR-QoL in patients treated with HFR versus Bicarbonate HD (BHD). We enrolled adult patients HFR treated for at least 6 months, with life expectancy greater than six months and without overt cognitive deficit. The recruited patients in HFR were matched for age, gender, dialytic vintage and performance in activities of daily living (Barthel index) with BHD treated patients. SF-36 questionnaire for the assessment of HR-QoL was administered. RESULTS: one hundred fourteen patients (57 HFR vs 57 BHD) were enrolled (age 65.413.5 years; dialysis vintage 5.4 (3.3-10.3) years; 53% males) from 18 dialysis non-profit centres in central and southern Italy. As result of matching, no difference in age, gender, dialytic age and Barthel index was found between HFR and BHD patients. In HFR patients we observed better values of physical component score (PCS) of SF-36 than BHD patients (P=0.048), whereas no significant difference emerged in the mental component score (P=0.698). In particular HFR patients were associated with higher Physical Functioning (P=0.045) and Role Physical (P=0.027). CONCLUSIONS: HFR is associated with better physical component of HR-QoL than BHD, independently of age, gender, dialysis vintage and invalidity score. Whether these findings translate into a survival benefit must be investigated by longitudinal studies.

Effect of hemodiafiltration with endogenous reinfusion on overt idiopathic chronic inflammation in maintenance hemodialysis patients: a multicenter longitudinal study.

Chronic inflammation is widely diffuse in maintenance hemodialysis (MHD) patients and is associated with poor survival. Hemodiafiltration with endogenous reinfusion (HFR) is a dialysis technique, highly biocompatible, able to adsorb proinflammatory cytokines and to decrease amino acids and antioxidants loss. These features could be helpful in MHD patients affected by idiopathic chronic inflammation, but this issue remains to be elucidated. We performed a multicenter longitudinal study to assess the effect of the switching from bicarbonate HD to HFR in patients with serum C-reactive Protein (CRP) > 5 mg/L coupled with albumin <4.0 g/dL in the last 6 months. We enrolled 24/176 (14%) patients, of which 20 patients were assessed at 4 months and 18 completed the study. We excluded 11 patients with evident causes of inflammation. At baseline, serum levels of CRP (18.7[7.0-39.4] mg/L) and albumin (3.5[3.3-3.7] g/dL) were significantly correlated (r = -0.49; P = 0.028). The effect on CRP and albumin was almost evident in the first 4 months and remained stable until to eighth month. A strict correlation (R = -0.49; 0.040) between percentage change of CRP (-35%) and albumin (+14%) after 8 months of HFR. These effects were associated with the reduction of IL-6, IL-1ß, and TNF-α and the increment of pre-albumin and leptin, whereas the serum levels of Branched Chain Amino Acid (BCAA) remained unchanged. In MHD patients affected by idiopathic chronic inflammation the switching from BHD to HFR is associated with improvement of inflammation. Whether these favorable effects may modify the outcomes of these high-risk patients needs to be confirmed by studies ad hoc.

Modifications of echogenicity of the testis during acute torsion may be a predictive factor of organ damage?

In the setting of symptoms of testicular torsion the absence of diastolic flow or color flow on Doppler ultrasound has traditionally prompted emergent scrotal exploration. This practice emanates from the difficulty on ultrasound of distinguishing salvageable testes from those that are not salvageable. We evaluated the changes of echogenicity in the course of testicular torsion of the testis to identify characteristics predictive of irreversible organ damage.

Variability of blood pressure in dialysis patients: a new marker of cardiovascular risk.

BACKGROUND: Hemodialysis patients have a high cardiovascular mortality, and hypertension is the most prevalent treatable risk factor. We aimed to assess the predictive significance of dialysis-to-dialysis variability in blood pressure in hemodialysis patients. METHODS: We performed a historical cohort study in 1,088 prevalent hemodialysis patients, followed up for 5 years. The risk of cardiovascular death was determined in relation to dialysis-to-dialysis variability in blood pressure, maximum blood pressure and pulse pressure. RESULTS: Variability in blood pressure was a predictor of cardiovascular death (hazard ratio [HR] = 1.242; 95% confidence interval [95% CI], 1.004-1.537; p=0.046). Also age (HR=1.021; 95% CI, 1.011-1.048; p=0.049), diabetes (HR=1.134; 95% CI, 1.128-1.451; p=0.035), creatinine (HR=0.837; 95% CI, 0.717-0.977; p=0.024) and albumin (HR=0.901; 95% CI, 0.821-0.924; p=0.022) influenced mortality. Maximum blood pressure and pulse pressure did not show any effect on cardiovascular death. CONCLUSION: Dialysis-to-dialysis variability in blood pressure is a predictor of cardiovascular mortality in hemodialysis patients, and blood pressure variability may be used in managing hypertension and predicting outcomes in dialysis patients.

Variability of pulse wave velocity and mortality in chronic hemodialysis patients.

We have already demonstrated that in chronic hemodialysis (HD) patients, the cyclic variations in both hydration status and blood pressure are responsible for changes in pulse wave velocity (PWV). The aim of this study is to verify whether the cyclic variation of PWV influences mortality in dialysis patients. We studied 167 oligoanuric (urinary output <500 mL/day) patients on chronic standard bicarbonate HD for at least 6 months. They performed 3 HD sessions of 4 hours per week. Patients were classified into 3 groups: normal PWV before and after dialysis (LL); high PWV before and normal PWV after dialysis (HL); and high PWV before and after dialysis (HH). The carotid-femoral PWV was measured with an automated system using the foot-to-foot method. Analysis of variance was used to compare the different groups. The outcome event studied was all-cause mortality and cardiovascular mortality. The PWV values observed were LL in 44 patients (26.3%); HL in 53 patients (31.8%); and HH in 70 patients (41.9%). The 3 groups of patients are homogenous for sex, age, and blood pressure. The HH group had a higher prevalence of (P<0.001) ASCVD. It is interesting that the distribution of patients in the 3 groups is correlated with the basal value of PWV. In fact, when the basal measure of PWV is elevated, there is a higher probability that an HD session cannot reduce PWV (<12 ms). A total of 53 patients (31.7%) died during the follow-up of 2 years: 5 patients in the LL group (11.4%); 16 in the HL group (30.2%); and 32 in the HH group (50.7%) (LL vs. HL, P=0.047; LL vs. HH, P<0.00001; HL vs. HH, P=0.034). We evidence for the first time that different behaviors of PWV in dialysis subjects determine differences in mortality.

Bone disease in patients with primary hypercalciuria and calcium nephrolithiasis.

In patients affected by calcium nephrolithiasis, primary hypercalciuria is frequently accompanied by bone demineralisation and increased susceptibility to fragility fractures. The relationship between bone loss and primary hypercalciuria is multifactorial. Organs and tissues which control calcium and phosphate metabolism - bone, intestine, and kidney - are actively involved in the pathogenesis of bone alterations which together form a multi-factorial metabolic disorder. We conducted a comprehensive evaluation of the published data concerning hypercalciuria and nephrolithiasis included in Medline from 1985 and 2005.

Inhibition of prostate efferent neurotransmission by amikacin.

BACKGROUND: It has been suggested that manipulation of the autonomic nerve supply to the prostate leads to loss of functional and structural integrity of the gland, and that these changes may be useful in treating prostatic diseases. This study investigates the effect of amikacin on prostate efferent neurotransmission in vitro, in both rat and human prostate samples. METHODS: Prostate samples, obtained from male Wistar rats and 8 patients undergoing endoscopic surgery for benign prostatic hyperplasia, were studied by measurement of isometric contraction induced by electrical field stimulation (EFS), noradrenalin, carbachol, serotonin and ATP, in the presence or absence of amikacin 10(-3) M in a low-Ca medium. RESULTS: Amikacin significantly reduced EFS-induced contraction of isolated rat and human prostate samples by 45 +/- 6.5% (P < 0.01) and 47 +/- 6% (P < 0.01), respectively. Contraction was restored after addition of calcium chloride 2 x 10(-3) M. Amikacin-induced relaxation in rat prostate samples was greater than the effect of magnesium and weaker than those of prazosin and verapamil, but comparable in extent with the latter. No significant effect was observed on rat prostate contractile response to noradrenaline as to ATP in the presence of amikacin. Rat prostate contraction to carbachol and serotonin was inhibited by 35 +/- 11% (P < 0.05) and 59 +/- 11.7% (P < 0.01), respectively, after addition of amikacin 10(-3) M. CONCLUSIONS: Amikacin reduces in vitro both rat and human prostate contraction elicited by pre-junctional stimulation, but does not affect prostate contraction evoked by post-junctional stimulation. Our results indicate that amikacin affects prostatic efferent neurotransmission.

[Caval involvement in advanced-stage non-seminoma testicular tumors: surgical strategy and long-term results]. / II coinvolgimento cavale nei tumori non seminomatosi del testicolo in stadio avanzato: strategie chirurgiche e risultati a lungo termine.

OBJECTIVES: The involvement of vena cava by residual masses after cytoreductive chemotherapy for bulky metastatic germ cell tumors is a rare but possible event. It could ensue by tumor invasion of the inferior vena cava (IVC), venous or neoplastic thrombosis, or by close adherence and encasement of IVC by scar tissue containing fibrosis or cancer; it usually occurs in right testicular neoplasms. In this study we evaluated a group of nine over 86 patients who underwent IVC (and possibly aortic) surgery for post-chemotherapy residual masses and we assessed long term oncological and functional efficacy of the procedure. MATERIALS AND METHODS: Between 1980 and 1997, 86 patients underwent retroperitoneal lymphadenectomy (RPLND) after induction or additional salvage chemotherapy. A subgroup of nine patients, all with primary tumors of the right testis in stage II C to III, showed evidence of caval involvement, four had caval thrombosis, seven exhibited caval invasion; in one case the IVC was displaced and compressed with no clear evidence of infiltration. Surgical management was: three en-bloc and four restricted vena caval resection and two thrombectomy. RESULTS: Of nine patients who underwent IVC surgery, six are alive and have no evidence of disease (follow-up 43-207 months), while three patients deceased for early progression (6-10 months). There were no major surgical complications: only one patient exhibited a significant lymphedema as a result of the primary vascular involvement or of following IVC surgery. CONCLUSIONS: IVC resection is sometimes necessary to complete RPLND of residual masses: it might be crucial to gain oncological clearance, with moderate long term morbidity even for extensive vena cava resections. Among patients eligible for postchemotherapy RPLND, caval involvement selects a higher risk subgroup that should be addressed to medical centers experienced in IVC neoplastic involvement.