[HFR vs HDF-ON line: plasmatic amino acids loss evaluation]. / HFR vs HDF on-line: valutazione della perdita aminoacidica plasmatica.

PURPOSE: The high convection dialytic techniques, such as hemodiafiltration (HDF), can cause the loss of important molecules such as growth factors, vitamins and amino acids. Hemodiafiltration reinfusion (HFR) is an HDF on-line process, using a sipping cartridge, able to remove uremic toxins and give back a "repaired" ultra-filtrate to the patient. We aimed to establish the plasmatic amino acid levels before and after dialysis in HFR vs. HDF on-line, with scrupulous attention to branched chain amino acids (BCAA) such as isoleucine, leucine and valine. These amino acids, often present with low plasmatic levels in hemodialyzed patients, seem to be related to a picture of malnourishment. METHODS: Eleven male patients on bicarbonate dialysis, for at least 1 yr, were evaluated (average dialytic age = 88 months, /average age = 67 yrs), with good dialytic efficiency and body mass levels, randomized in HFR or HDF on-line (filter PAN AN 69) for 1 week of treatment, respectively. The different results of each method were controlled for the same patient. Blood samples were taken before and after dialysis in each 2nd hemodialytic weekly session. Total amino acids, essential, non-essential and BCAA were determined by gas-chromatography. RESULTS: There was no difference detected in pre-dialytic plasmatic levels of analyzed amino acids between the two groups. In post-dialysis, HDF patients demonstrated a total essential, non-essential amino acid and BCAA higher loss rate, compared to HFR patients. Post-dialysis amino acid level averages were: total amino acids in HDF 1852 +/- 302.6 micromol/L, in HFR 2395 +/- 492.8 micromol/L (p = 0.018); essential amino acids in HDF 428.8 +/- 118.2 micromol/L, in HFR 510.3 +/- 129.3 micromol/L (p = 0.022); non-essential amino acids in HDF 1176 +/- 213 micromol/L, in HFR 1546 +/- 339.2 micromol/L (p = 0.01); BCAA in HDF 242.7 +/- 83.42 micromol/L, and in HFR 286.7 +/- 89.9 micromol/L (p = 0.03). CONCLUSIONS: Since low plasmatic BCAA levels are related to anorexia and malnourishment, the loss of these amino acids can be important in the dialytic technique choice. HFR can offer an outstanding advantage, combining a high convection treatment with medium molecule removal, without compromising physiologic molecule loss.

[Safety in dialysis rooms. Biologic risks]. / La sicurezza in sala dialisi. Il rischio biologico.

The search for quality in the health service cannot lead aside the safety of its operators and users, subject to the well defined parameters of Law 626. This study makes a preliminary examination of the accidents occurring in our Health District which comprises three hospitals, 600 beds and 1,800 employees. A total of 172 accidents have been reported. The percentages can be broken down between the various sectors: 73% of accidents involve nurses, 9% involve doctors and 1% administrative personnel. The greatest risk in hemodialysis is the biological factor (through accidental cuts or pricks which account for 67% of the accidents reported) and involves humans (both patients and personnel), monitors and environments as the sources of pathogens. The most frequently isolated germs are E. coli and Pseudomonas. It has been shown that prevention is above all based on the accuracy with which procedures are followed. The risk of hepatitis C has not yet been resolved, as is affinned in a review reported in the study. The HIV risk gives the greatest cause for concern, even if only 0.2% after exposure compared to 15-36 for HbsAg. Compliance with universal rules for prevention and post-exposure procedures provides an adequate guarantee for prevention.

[Chronic pain during dialysis. Pharmacologic therapy and its costs]. / Il dolore cronico in dialisi. Terapia farmacologica e i suoi costi.

BACKGROUND: There is very little research into the problem of chronic pain in dialysed patients, despite the fact that pain is a widely diffused phenomena amongst these patients. This work proposes to evaluate the intensity of pain, supply a scale of levels of intervention, with an indication of the consumption and relative costs of pharmacological therapies. METHODS: 37 out of 100 patients undergoing haemodialysis suffer chronic pain. Aetiological research has shown that osteoarticular pain (24 cases), is the most common, peripheral vascular pain (3 cases), is subjectively and indirectly considered to be the most serious form. Nine cases have presented pain of a neuromuscular origin, whilst one case of a neoplastic origin. The degree of personal invalidism shows serious invalidism in 11 cases. RESULTS: The therapeutic file that forsaw four levels of pharmacological intervention (1st levels: FANS, 2nd level: Codeine+paracetamol, 3rd level: Buprenorphine, 4th level: Morphine for os), accompanied by instrumental and pharmacological support intervention, has proved to be indispensable in confronting the problem. Through pharmacy data, we have noticed a progressive increase over the year in the use of analgesic medicines, of which we can confirm the effectiveness, tolerability, low level of side-effects, at low costs. CONCLUSIONS: In our opinion chronic pain in dialysed patients should not be neglected. The perfection of diagnostic techniques, the discovery of pain-killers with reduced side-effects, the multidisciplinary approach, and reduced costs of treatment, are all valid arguments in favour of an intervention that improves the quality of life of these patients, already so compromised by the nature of the illness itself.

[Nephrotic syndrome refractory to conventional therapy]. / Sindrome nefrosica refrattaria alla terapia convenzionale.

BACKGROUND: Prednisone is the choice medicine in Nephrotic Syndrome (NS) treatment, possibly associated with immunosuppressor medicines (cyclophosphamide or chlorambucil), either in case of NS resistance at cortisone therapy or with frequent relapses. Cyclosporin A (CyA) use has been recently proposed, due to its inhibitory effect on the IL2 and lymphokine release, with a permeabilizing effect on the glomerular membrane. The purpose of this study is to evaluate the CyA antiproteinuric effectiveness with NS conventional therapy refractory patients. METHODS: Six patients (3 females and 3 males) have been treated with CyA (4 +/- 0.5 mg/Kg/die) associated with low corticosteroid dosages. RESULTS: During the treatment, proteinuria reduced in 5 patients, at less than 1/3 of pre-treatment values, for 4 patients this happened starting from the 2nd month of therapy, while after the 12th for the fifth patient. The sixth patient has now a 2/3 reduction compared to the initial one and he is at the 3rd month of therapy. During the CyA treatment, further to the proteinuria reduction, a total proteinemia values increase and a cholesterolemia and tryglyceridemia reduction has been observed, while creatinine and PA have not changed. CONCLUSIONS: Four out of the six treated patients have been respectively under therapy for 2,3,12,30 months. Two stopped CyA therapy: one after 18 months due to clinical stability, still present after 2 years from interruption; one after 9 months with a stable clinical picture for just three months, since she was longing for a pregnancy, achieving a quick proteinuria relapse.

Correlations between bone histopathology and serum biochemistry in uremic patients on chronic hemodialysis.

To define which noninvasive investigations are of value in predicting bone histology, we analyzed transiliac bone specimens (66 biopsies, 14 autopsies) from 80 uremic patients on chronic dialysis. Results were compared with values of different measurements of parathyroid hormone (PTH), alkaline phosphatase (APH), osteocalcin, calcitonin, baseline and post-deferroxamine (DFO) aluminium (Al),--beta 2 microglobulin, ferritin and bone mineral density. Among histomorphometric parameters, woven osteoid, active osteoblastic surface and resorption surface showed the best correlations with dynamic and biochemical marks of active bone metabolism. Among biochemical parameters, intact PTH and APH were better related to histomorphometric and dynamic bone parameters than other PTH measurements as well as osteocalcin, while calcitonin was related to no parameters. Stainable Al alone, and not total bone Al content was related to bone histology. Baseline Al was related to lamellar osteoid, while post-DFO Al was related to stainable Al. beta 2 microglobulin was positively related to active osteoid surface and ferritin was inversely related to the mineral apposition rate, while bone mineral density was related only to total bone volume. We conclude that, though definite diagnosis requires the use of histological methods, few simple biochemical parameters may offer insight to the bone metabolic status, useful to the physician in day to day clinical practice.

[Heart failure resistant to drug therapy. Nephrologic approach]. / Scompenso cardiaco resistente ai farmaci. Approccio nefrologico.

BACKGROUND: The congestive heart failure (IV cl. NYHA) refractory to medical therapy, can be treated with ultrafiltrative method such as extracorporeal ultrafiltration (UF), intermittent veno-venosus hemofiltration, intermittent peritoneal dialysis (IPD) or chronic ambulatory peritoneal dialysis (CAPD). METHODS: Sixty-one patients suffering from SCC have been managed by combining medical therapy with ultrafiltrative treatment. RESULTS: 28% (17 patients) died within a week from ultrafiltrative therapy beginning. 39% (24 patients) took up to respond to medical therapy (responders). 33% (20 patients) didn't give a proper response to pharmacological therapy (non responders), therefore a ultrafiltration program with chronic ambulatory peritoneal dialysis (CAPD) has been undertaken. Among ultrafiltrative methods applied to patients, IVVH is the most effective. Clinical parameters analysis, relevant to dehydration acute phase, points out: an evident loss of corporeal weight between dehydration pre-post phases in all 3 groups, with statistically significant results; a SAP values reduction between the beginning and the end of treatment in all 3 groups; a PAD values reduction in the group of deceased and non responders. This value remains stable in responders group. Non responders patients, inserted in a ultrafiltration program with CAPD present the following survival rate: 55%: 6 months; 35%: 1 years; 15%: 4 years. These patients maintain a good self-management in 50%, sufficient in 35% and totally partner-dependent in 15%. CONCLUSIONS: Ultrafiltration method together with pharmacological therapy allows a resetting of neuro-endocrine and electrolytic system in refractory congestive heart failure patients and a recovery of a pharmacological response. Without such a response a cardio-circulatory balance can be maintained through a CAPD method.

[Peritoneal dialysis and chronic dobutamine, two experiences contrasted. Possible role and indications in refractory cardiac decompensation]. / Dialisi peritoneale e dobutamina cronica, due esperienze a confronto. Possibili ruoli ed indicazioni nello scompenso cardiaco refrattario.

UNLABELLED: The number of patients who develop heart failure (HF) is increasing and is expected to increase further in the next decade. Despite the availability of an ever-widening array of pharmacological therapy, patients with end-stage HF have a poor long-term prognosis. Little attention has been paid to alternative non-conventional therapy for these patients. The aim of this non-randomized study was to describe two non-conventional approaches in patients with HF, refractory to conventional medical therapy. The feasibility and long-term efficacy of a continuous ambulatory peritoneal dialysis (CPAD: 20 patients) or dobutamine intermittent infusions (DOB: 11 patients) was analysed: the mean dobutamin dose was 5 gamma/kg/min, and the interval period treatment ranged from 12 hours/day to 12 hours/week. RESULTS: Both treatments were feasible and non major procedure complications occurred. The 6 and 12 month survival rates were 55% (14/20 patients), 35% (9/20 patients) and 36% (6/11 patients), 18% (3/11 patients) in the CAPD patients and DOB patients, respectively. All patients survived at one year (38% = 12/31 patients) documented a significant functional improvement and quality of life. The conclusions is drawn that the use of CAPD and DOB should be considered in those with refractory HF, in whom medical therapy has failed and in whom home training is considered feasible. Further studies are necessary to define those patients who will benefit from one of these strategies and to confirm these preliminary data.

[Medical nephropathies: what has changed in 20 years]. / Nefropatie mediche: cosa è cambiato in 20 anni.

The authors analyse the series of patients with medical nephropathy undergoing renal biopsy between 1973 and 1993 in order to make a diagnostic and prognostic comparison between the first (ID) and second (IID) decade. Clinical indications for biopsy, which became more precise during the second decade, led to the diagnosis of fewer patients with normal histology; the introduction of ME and IF allowed non-significant histological conditions to be reduced during IID; echo-guided biopsy has led to a reduced number of post-biopsy complications in IID compared to ID. Epidemiological analysis reveals the reduction of focal glomerulosclerosis in IID in favour of glomerulonephritis with IgA deposits in correlation with the use of IF; the increase in mebranous glomerulonephritis secondary to increased antigenic stimuli; reduced acute post-infective glomerulonephritis and membrane-proliferative glomerulonephritis owing to an improved prophylaxis of sources of infection. Among the patients undergoing renal biopsy and commencing dialysis an increase was observed in IID in the number of cases of membranous glomerulonephritis or caused by IgA deposits. There was an increased interval between biopsy and the start of dialysis in IID compared to ID, in spite of fewer patients receiving immunosuppressive therapy. This was probably due to the increased number of pathologies with a slower evolution, thus justifying the postponement of the start of dialysis.

[Cost methodologies in dialysis in relation to the Italian National Health Service]. / Metodologie dei costi in dialisi in rapporto all'azienda salute italiana.

This work analyses the economic aspects of dialysis in Italy in relation to government resources allocated to the health service in general. The authors illustrate the procedures used to estimate the resources required by the dialytic programme. The costs of dialytic programmes in different cities and at different periods in the history of the Italian health service are compared. A concrete example is outlined of the economic management of dialysis and the authors demonstrate how the results were obtained using cost analysis.

Effects of fluid volume changes during hemodialysis on the biophysical parameters of the skin.

Water plays an important role in maintaining skin suppleness and elasticity. We used hemodialysis as a model to investigate the effects on biophysical properties of the skin induced by removal of fluids and water from the body. The following parameters have been investigated before and immediately after a hemodialysis session: body weight, skin elasticity and distensibility, skin hydration, transepidermal water loss (TEWL) and skin thickness. A significant decrease was recorded after treatment in body weight, skin thickness (p < 0.01) and skin elasticity (p < 0.01). Significant linear correlations were found between stratum corneum water content, skin distensibility and TEWL. The data reveal that rapid removal of body fluids influences skin biophysical properties: early changes in skin thickness and ground substance occur in the dermis and affect mechanical properties of the skin. The decrease in water content in the upper layers of the skin occurs at a later stage and influences skin hydration rather than TEWL. This model is a useful tool to investigate water kinetics through the skin.

[Variability of the response to recombinant human erythropoietin in patients undergoing hemodialysis treatment]. / Variabilità di risposta all'eritropoietina umana ricombinante nei pazienti in trattamento emodialitico.

The paper assesses the existence of possible interference between dialysis and the response to human recombinant erythropoietin administered i.v. in a group of patients undergoing regular dialysis. The results obtained show that the time taken to reach the set hemoglobin target (Hb 10 g%) was shorter in hemodiafiltered (HDF) patients compared to those receiving bicarbonate dialysis (BD). A plausible explantation may be the different depurative characteristics and the greater degree of biocompatibility of alternative dialysis which is able to achieve a more rapid cellular response to pharmacological stimulation.

[High-efficiency membranes and the dialysis solution]. / Membrane ad alta efficienza e bagno di dialisi.

During this work through the total bacterial count and of the pseudomonas and the determination of the positive substances to Limulus Amebocyte Lysate test, bacterial pollution of the liquid bicarbonate concentrate has been determined together with the influence that preparation conditions and the entity of interval between the said preparation and utilization of concentrates have on it. Through the evaluation of the cardiac rate and the systemic arterial pressure, we have studied the influence of the bacterial pollution on the clinical of the patient. Analysing the obtained data we can point out that the liquid bicarbonate concentrate present an elevated degree of contamination which feels the effects of the production and storage procedures. The remark of inverse correlation between systemic arterial pressure and endotoxin level of the dialysate seems to reconfirm the importance of the bacterial contamination on the clinical of the patient.

[Changes in the biomechanic property of the skin after hemodialysis treatment]. / Variazioni delle proprietà biomeccaniche della cute in seguito a terapia emodialitica.

Skin extensibility in 21 subjects (belonging to two different age groups) undergoing hemodialysis has been investigated. Measurements have been performed on the forearm before and after two hours of dialytic treatment. A significant decrease of skin extensibility (P less than 0.02) has been recorded in the elderly prior to the dialytic procedure; the data is consistent with an increased dermal water content. Water removal during treatment led to normalization of extensometric levels (P less than 0.05). However, improvement of skin extensibility is not directly related to the amount of water withdrawn. The study support the importance of water in determining skin viscoelastic responses; hemodialysis is a useful model to monitor the effects of water on skin biomechanics.