[Low-protein dietary therapy in patients with chronic kidney disease]. / Terapia dietetica ipoproteica del paziente con IRC.

Several prospective studies and meta-analyses including the recent Cochrane meta-analysis have demonstrated that reducing the protein content in the diet delays renal death and the start of dialysis in patients with chronic kidney disease (CKD). Reducing the dietary protein intake offers other benefits such as lowering accumulation of uremic toxins and circulating phosphates and improving symptoms and metabolic derangements. Following the publication of the Cochrane meta-analysis, some of the most renowned experts in Italy on dietary therapy in the CKD patient established a working group within the Italian Society of Nephrology (SIN), the ''Nephrontieres'' project. The current supplement of GIN presents the views of the members of the ''Nephrontieres'' group on a range of issues related to dietary therapy in CKD. A CME program for Italian nephrologists also originated from the collaborative work of the group.

[Low-protein diet in Italy today: the conclusions of the Working Group from the Italian Society of Nephrology]. / La dieta ipoproteica oggi in Italia: le conclusioni del Gruppo di Lavoro SIN.

The high estimated prevalence of chronic kidney disease (CKD) forcefully supports the need for collaboration among nephrologists, cardiologists, diabetologists and general practitioners, to reduce the cardiovascular risk of CKD patients and delay the start of dialysis. Many studies confirm that reducing the dietary intake of proteins improves uremia as well as acid-base and phosphorus disorders without exposing the CKD patient to the risk of malnutrition. The possibility of delaying renal death and the start of dialysis by almost one to two years is also recognized, thanks in part to the antiproteinuric effect of low-protein diets supplemented with keto acids and essential amino acids. Reducing the dietary protein intake delays the start of dialysis independently of the effect of renin-angiotensin system (RAS)-active antihypertensive drugs. Reduction of the dietary protein intake is indicated in patients with a glomerular filtration rate <25 mL/min (CKD stages 4 and 5). Some situations may, however, require an earlier switch to a low-protein diet, e.g., high proteinuria, renal function worsening at more than 5 mL/min/year, diabetes, and metabolic decompensation. If well designed and properly carried out, reduction of the dietary intake of proteins is not associated with low serum albumin levels or malnutrition, and does not affect patients death. Today, highly palatable, high-quality reduced protein preparations are widely available to reduce the protein intake of CKD patients.

[Socioeconomic aspects of dialysis treatment]. / Aspetti socio-economici del trattamento dialitico.

The Italian research institute CENSIS recently estimated that the total monetary cost of dialysis in Italy reached almost 2,700 billion old lira (about 1.4 billion euros), with more than a quarter of that as social costs largely borne by families. The yearly cost in Italy for acetate and bicarbonate dialysis has been estimated at Euro 35,000 per patient and is steadily rising. Delaying renal death and start of dialysis by an average of two years is one of the most relevant ''monetary'' benefits of low-protein diets, even more so when considering that about half of all elderly patients starting dialytic treatment will die within three years. Reduced intake of phosphorus is another benefit of low-protein therapies that is associated with substantial monetary savings, thanks to a reduced need for phosphate-binding agents. Highly palatable preparations of low-protein content are already available, and are probably already self-paying if the savings from reduced prescription of phosphate binders are accounted for.

[Compliance with low-protein diet in patients with chronic kidney disease]. / Compliance alla dieta nell'insufficienza renale cronica (IRC).

Direct evaluation of the compliance with nutritional therapy is possible only in clinical trials while indirect methods such as self-reporting and interviews are used in clinical practice. Dietary history is the best method to evaluate nutritional habits in clinical practice; the same holds true for the compliance with low-protein diets in patients with chronic kidney disease. Other indexes to assess dietary compliance should be simple and easy to use in the clinical practice. Some of such functional and biological markers are blood urea nitrogen and serum phosphate levels (indirect markers of dietary intake), weight and body mass index (indirect markers of energy intake), and daily urinary excretion of nitrogen and sodium (indirect markers of protein and salt intake). The compliance with a low-protein diet in patients with chronic kidney disease is strongly influenced by psychosocial factors (e.g., satisfaction and comprehension), and thus by the supporting role of the physician and the dietitian, but also by the level of renal function and food characteristics. It must be pointed out that even a protein intake reduction of 0.2 g/kg/day improves blood urea nitrogen, phosphate levels, and acidosis.

[From evidence to practice: a difficult but not impossible itinerary]. / Dalla evidenza alla pratica: un percorso difficile ma non impossibile.

In recent years, evidence-based medicine (EBM) has acquired its own dignity and cultural identity, and increasing importance. EBM helps doctors understand that the uncertainties of medicine must be analyzed quantitatively in order to rationalize and systematize the information gathered from clinical observation; on the other hand, it provides them with suitable instruments to estimate the performance of diagnostic tests and the efficacy of drugs. One of the main merits of EBM has been the progressive spread of randomized controlled trials as the gold standard for evaluating the effectiveness of treatments. EBM's primary objectives can be summarized by the following points: 1) To transform the physicians' need for information into questions that may be answered (ie, formulate the questions); 2) To find in an as efficient way as possible the best evidence to answer these questions; 3) To critically evaluate the evidence obtained (ie, assign a weight to it) in order to determine its validity (ie, its approximation to the truth) and its usefulness (ie, its concrete clinical applicability); 4) To introduce into clinical practice the conclusions drawn from the results; 5) To estimate individual physicians' performance (ie, one's own conduct and efficiency). EBM's advantages are not only that physicians have acquired a method to search for the right evidence and to apply diagnostic and therapeutic procedures, but, more importantly, that it has provided them with the only tool for true quality improvement, namely the critical appraisal of their own work. Unfortunately, the latter is too often based on a different type of EBM: Evidence-Based Medicine.

[Census 2004 of the Italian renal and dialysis units--Abruzzo-Lazio-Marche-Molise-Umbria]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Abruzzo-Lazio-Marche-Molise-Umbria.

The Italian Society of Nephrology (SIN) promoted a national survey in order to collect detailed information from all Italian renal and dialysis units. This is the second paper, following the first one which focused on three northwestern regions, aim-ing to present the results of the survey. In this paper, data from the central regions (Abruzzo, Lazio, Marche, Molise and Umbria) are reported. The most relevant findings in the five regions were: A) epidemiology--prevalence of dialysis patients = 742, 781, 731, 814, 768 per million population (pmp); prevalence of transplanted patients = 162, 153, 296, 134, 304 pmp; incidence of dialysis patients = 175, 179, 184, 143, 162; gross mortality of dialysis patients = 12.3, 11.8, 15.9, 13.4, 14.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 90, 87, 82, 94, 80%, central venous catheter = 7, 10, 15, 4, 17%; vascular graft = 3, 3 ,3, 2, 3%. B) Structural resources--number of hospital beds = 52, 43, 39, 62, 44; dialysis places = 205, 260, 203, 301, 226. C) Personal resources--renal physicians = 50, 78, 47, 53, 47 pmp; renal nurses = 162, 172, 180, 224, 245 pmp; each renal physician takes care of 15, 10, 16, 15, 17 dialysis patients and each renal nurse cares of 4.6, 4.6, 4.1, 3.6, 3.1 dialysis patients. D) Activity--admission to hospital= 2334, 1689, 2652, 1255, 1377 pmp; renal biopsies = 59, 84, 97, 19, 80 pmp. Despite the differences we find among the regions, most indexes are similar and show a satisfactory level of renal care provided in the central regions examined.

[Update of the Italian Society of Nephrology Project No. 1 of the 2004-2006 SIN programme]. / Update sul progetto SIN n. 1 del programma SIN 2004-2006: qualità e accreditamento delle strutture di nefrologia, dialisi e trapianto.

In the last few years the Italian Society of Nephrology has addressed many technical-scientific and management aspects to better patient satisfaction. Project No. 1 of the 2004-2006 programme on 'Quality and Accreditation of National Renal Units' focuses on four essential points. The first is the questionnaire mailed to all the Presidents and Regional Delegates on the relationship between Nephrology units, Local Government Health-System and the Regional Healthcare Agency. The results evidence that the 'political' decision-making power of nephrologists decreases in the absence of a national strategy. The second point, in collaboration with the National Census Group, includes the quality analysis and the standardization of resources (human and structural) and management of the Renal Units. The third point is based on 'Educational Courses for Quality and Accreditation' held in Rome (3-5 October 2005: L'Accreditamento all'Eccellenza dell'Unita' Operativa di Nefrologia, Dialisi e Trapianto; 17-19 October 2005: Il Manuale di Accreditamento della Specialità di Nefrologia). The courses aim at training members responsible for each region to hold courses in their specific region to create a network including each single Renal Unit to create an acceptable homogenous language on the models of analysis and on the correct use of 'The Guide for Excellence Accreditation'. The fourth point concerns both the on-line Guide for Excellence Accreditation and 'Peer Review Accreditation' and the NEQUASY (Nephrology Quality System) project. The manual must be 'user friendly' allowing each Centre to self-evaluate using national and regional standards.

[Nurses' professional responsibility]. / La responsabilità professionale dell'infermiere.

As managed care relevance is growing, several old issues related to personal institutional responsibility are increasing among practitioners. Therefore, as a professional figure a nurse bases his/her job on a mix of personal knowledge and skills along with training, and he/she is responsible for giving advice in line with professional care standards. In addition, he/she is in charge of the treatment pattern agreed with the patient. However, nursing is a much more complex job, which leads professional figures facing the controversial issue of combining institutional responsibility and nursing professional tasks and duties daily. As far as nursing institutional responsibility is concerned, different view points or approaches can be applied to investigate it. The most common one is the legal approach, yet this is not the most appropriate one. Therefore, our professional background is mainly based on a management prospective rather than a legal one; dealing with the issue legally would lead, essentially, to a summary of laws and regulations without any kind of argumentative discussion. Consequently, this study aimed to analyze nurses' institutional responsibility by approaching the issue from an innovative human resources management prospective; therefore, defining the gap between nursing institutional responsibility and its tasks.

[Italian Registry of Dialysis and Transplantation: 1996-2001 experience]. / Registro Italiano Dialisi e Trapianto. Esperienza 1996-2001.

The Italian Registry of Dialysis and Transplantation (RIDT) was born in 1996 under the aegis of the Italian Society of Nephrology, and it is organized as a federation of regional registries. This study aimed to completely revise the epidemiological data collected during the first 5 yrs (1996-2001) of RIDT activity to evaluate the trends of the main epidemiological features. During this period, regional registries were not always able to assure complete and exhaustive information according to RIDT requirements, owing to different levels of organization and functioning. To avoid any possible error in data analysis, information inadequately assessed was refused. The incidence of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT) in Italy has increased from 114 pmp in 1996 to 139 pmp in 2001, that means an increase of 3.5%/yr, corresponding to 5718 patients during 1996 and 8000 patients during 2001. Primary renal diseases (according to the EDTA) in incident ESRD patients are vascular and diabetic nephropathy. Main dialysis modality in incident patients was hemodialysis (HD) (85%), while peritoneal dialysis (PD) was only 15%; pre-emptive transplantation was a very unusual modality. The prevalence of ESRD patients at 31 December was 693 pmp in 1996 and 827 pmp in 2001; among dialysis patients, the corresponding rates were 575 pmp and 657 pmp, respectively. Consequently, the number of dialyzed patients increased, respectively, from 28892 to 37919. The prevalent dialysis modality was bicarbonate dialysis in 74% of cases, followed by hemodiafiltration (HDF) in 15%, continuous ambulatory peritoneal dialysis (CAPD) in 7% and APD in 3%. The gross mortality rate in dialyzed patients was stable during this period, at approximately 14%, the main causes of death being cardiovascular diseases and cachexia.

[Continuous medical education]. / L'educazione medica continua.

Continuing medical education is an essential element of state-of-the-art medical practice. Continuing medical education as structured today in most countries, must be able to guarantee the quality of continuing medical education and its independence. There should, therefore, be an independent professional body at national level responsible for assessing and guaranteeing both quality and independence. This body will also have the power to oversee the participation of medical specialists in continuing medical education. A system of credits should was developed to express the professional value of continuing medical education activities. Each activity is credited with a certain score, which can be awarded to the participating specialist. Continuing medical education should remain an ethical obligation subject to the disciplinary authority of the profession itself. Continuing medical education should be both an individual and also a collective obligation of the profession; in order to promote and make it effective, each member state must provide the means of making continuing medical education available to all physicians. For the above reason the CME is a strategic way to improve the quality of the health system. In Italy new way to obtain CME credits are going to be issue in the near future.

[Regional institutional accreditation measures for nephrology in Italy]. / I provvedimenti regionali di accreditamento istituzionale per la nefrologia in Italia.

The process of institutional accreditation has been initiated in Italy too because it is considered to be the criterion upon which new relations within the National Health Service must be based. These relations include payment for the service as well as choice of quality assessment and revision of the activities carried out and the services provided. This paper describes the regulations in force regarding Institutional accreditation and the specific regulations of Italian regional credit laws on nephrology. The Regions examined are Lazio, Campania, Marche, Basilicata and Lombardy. A synoptic table showing the most important criteria, differentiated according to each region, is also included.

Short daily hemodialysis: blood pressure control and left ventricular mass reduction in hypertensive hemodialysis patients.

Several retrospective and uncontrolled prospective studies reported blood pressure (BP) normalization and left ventricular mass (LVM) reduction during daily hemodialysis (DHD). Conversely, the burden of these major independent risk factors is only marginally reduced by the initiation of standard thrice-weekly dialysis (SHD), and cardiovascular events still represent the most common cause of death in hemodialysis patients. Therefore, we performed a randomized two-period crossover study to compare the effect of short DHD versus SHD on BP and LVM in hypertensive patients with end-stage renal disease. We studied 12 hypertensive patients who had been stable on SHD treatment for more than 6 months. At the end of 6 months of SHD and 6 months of DHD in a sequence of randomly assigned 24-hour ambulatory BP monitoring, echocardiography and bioimpedance were performed. Throughout the study, patients maintained the same Kt/V. A significant reduction in 24-hour BP during DHD was reported (systolic BP [SBP]: DHD, 128 +/- 11.6 mm Hg; SHD, 148 +/- 19.2 mm Hg; P < 0.01; diastolic BP: DHD, 67 +/- 8.3 mm Hg; SHD, 73 +/- 5.4 mm Hg; P = 0.01). The decrease in BP was accompanied by the withdrawal of antihypertensive therapy in 7 of 8 patients during DHD (P < 0.01). LVM index (LVMI) decreased significantly during DHD (DHD, 120.1 +/- 60.4 g/m(2); SHD, 148.7 +/- 59.7 g/m(2); P = 0.01). Extracellular water (ECW) content decreased from 52.7% +/- 11.4% to 47.6% +/- 7.5% (P = 0.02) and correlated with 24-hour SBP (r = 0.63; P < 0.01) and LVMI (r = 0.66; P < 0.01). In conclusion, this prospective crossover study confirms that DHD allows optimal control of BP, reduction in LVMI, and withdrawal of antihypertensive treatment. These effects seem to be related to reduction in ECW content.

Survival of vascular access during daily and three times a week hemodialysis.

AIM: A major cause of morbidity for hemodialysis patients is vascular access failure and/or occlusion. It is commonly believed that an increased frequency of dialysis sessions, among other factors, might lead to a higher rate of fistula complications. MATERIALS AND METHODS: To evaluate if patients on daily hemodialysis carry a higher risk of vascular access occlusion, we examined the incidence rate of access occlusion and the survival function of native vascular accesses in patients undergoing daily dialysis (DD; n = 24) as compared to patients on standard three times a week hemodialysis (TWD; n = 124). RESULTS: The mean follow-up time was 3.6 years. In the TWD group 42 patients had a first-access closure, whereas only 2 patients out 24 had a similar event in the DD group. The proportion of first-access closure was 33.9% for TWD and 8.3% for DD (p < 0.01). The incidence rate was 9.8 (95% CI: 7.2 -13.2) and 2.2 (95% CI: 0.4 - 7.1) events per 100 patient-years for TWD and DD, respectively. The rate difference was 7.6 (95% CI 3.4 - 11.9) events per 100 patient-years, and the unadjusted risk ratio was 4.5 (95% CI: 1.2 - 16.9; p < 0.01). The mean vascular access survival before closure was 3.3 years in TWD and 3.7 years in DD. Survival curves, obtained considering the first-access closure as the endpoint, showed a significant difference between DD and TWD (log-rank 5.16; p < 0.05). In a Cox-proportional hazard model the relative risk (RR) of vascular-access closure in TWD remained significant (RR = 4.3; 95% CI 1.1 - 18.2) after adjustment for age. CONCLUSION: The results of this observational study, conducted on a limited number of DD patients, suggest that daily dialysis might not have an adverse prognostic significance for access closure.

Left ventricular hypertrophy in daily dialysis.

Cardiac hypertrophy, a well-known independent risk factor for cardiovascular death, is a very frequent complication in ESRD patients. Its frequency tends to be even higher in dialyzed patients due to the fact that the current dialytic treatments are unable to keep under a satisfactory control the various responsible factors and particularly the blood pressure, which is largely the most important. Daily hemodialysis, a more frequent schedule consisting of 6-7 sessions/week lasting 2 or more hours, has definitely proved its superiority in controlling blood pressure and in improving anemia, and thus has the requisites for positively influencing cardiac hypertrophy. In fact, a series of studies, both retrospective and prospective, performed during the last years by our group, have confirmed that this new, more frequent and thus more physiological schedule, is able not only to stop the progression of the cardiac hypertrophy in uremic patients but also to revert toward the normality, in a relatively short time. This appears to be essentially a consequence of the excellent blood pressure control, which in turn derives from the easier control of the true dry weight, achievable with this type of dialytic treatment.