Burn-out in the dialysis unit.

The management of human resources is definitely one of the most important chapters in managerial activities. So, the involved participation of personnel is one of fundamental importance for all systems of quality management. The aim of this study is to analyse satisfaction of personnel in dialysis units. We administered a questionnaire subdivided into 6 basic sections with 34 items regarding the work environment, the material, the environmental climate, the objectives, the quality, and justifications and suggestions. We received 298 replies to the questionnaire, of which 72 from doctors (D) (24.2%) and 226 from nurses (N) (75.8%). From a possible maximum score of 170, the scores reached were 115 points for the D and 113 for the N. It is obvious that N considered the environmental climate, the objectives and the quality of the services to be inferior compared to D. Thirty-nine percent of D and 27% of N were very critical of the items analyzed. A second step was dedicated to the administration of the questionnaire to the dialysis patients to verify if there was agreement. One hundred and twenty-five patients (5.7%) (randomized in a single dialysis unit for age and sex), of a total of 2170 patients responded. Their answers were then compared with those of the personnel. The data of our study showed that most of the personnel did not receive counseling about uncertainties, expectations did not correspond to reality and there was distrust and scarcity of involvement. These elements appeared to cause irritation and dissatisfaction and if not resolved are responsible, together with technical and environmental factors, for the serious burn-out syndrome in the personnel of dialysis units.

Long-term L-carnitine administration reduces erythropoietin resistance in chronic hemodialysis patients with thalassemia minor.

BACKGROUND AND AIM: Both thalassemia and carnitine deficiency represent independent causes of erythropoietin resistance, and thus anemia, in uremic patients. We evaluated the unknown long-term effects of L-carnitine administration in ß-thalassemic on chronic hemodialysis. METHODS: We studied twelve subjects (M = 8; F = 4) affected by ß-thalassemia minor (ß-thal; HbA2 level = 6.6 ± 0.6%) and forty non-thalassemic subjects (M = 24; F = 16) as controls (C), on chronic hemodialysis treatment. Patients and controls were at target hemoglobin levels (11-12g/dl) prior to the study and underwent to i.v. L-carnitine administration for a one year period-time. RESULTS: Groups were comparable for age, gender, serum levels of hemoglobin (Hb), iron, ferritine, PTH and aluminum, transferrin saturation, and dialysis modalities. During the study both groups showed significant Hb increase and erythropoietin (EPO) decrease; as a difference, such changes emerged at the 3rd month in C but at the 8th month in ß-thal. At start, during the dialysis session the erythrocyte MCV reduced in C but not in ß-thal (65.3 ± 3.2 to 65.5 ± 3.2 fl; NS); along carnitine administration period, however, MCV during dialysis decreased also in ß-thal, starting since the 9th month of treatment. CONCLUSION: This study provides evidence of the lowering of EPO resistance in ß-thalassemia patients on hemodialysis due to long-term carnitine administration. Thus, prolonged carnitine supplementation should be suggested to patients on dialysis affected by ß-thalassemia with poorly responsive anemia, or requiring large doses of erythropoietin.

Cardiac vascular calcification and QT interval in ESRD patients: is there a link?

We will present our experience and our preliminary data about the correlation between cardiac calcification and QT interval (and QT dispersion) in uraemia. We studied 32 haemodialysis (HD) patients (age 69 +/- 16 years, time on dialysis 32 +/- 27 months) and 12 chronic kidney disease stage 4 (CKD-4) patients (age 66 +/- 17 years, uraemia duration 38 +/- 16 months). The patients were characterized by a good mineral control, as shown by serum phosphate levels (3.6 +/- 1.3 mg/dl in CKD-4 and 4.3 +/- 1.6 mg/dl in HD patients) and Ca x P product (46 +/- 17 and 49 +/- 16 mg(2)/dl(2), respectively). The parathyroid hormone levels were higher in HD than CKD-4 patients (p < 0.0001). A TC score >400 was found to be highly prevalent in both groups. Significantly more HD patients (62.5%) showed cardiac calcification than CKD-4 patients (33%; p = 0.01). The patients were matched for TC scores higher or lower than 400. The two groups differed by gender (p < 0.05), age (p = 0.026), frequency of diabetes mellitus (p < 0.01), uraemia follow-up period (p < 0.001), low-density lipoprotein cholesterol level (p = 0.009), Ca x P product (p = 0.002), parathyroid hormone level (p < 0.0001), and corrected QT dispersion (p < 0.0001). The QT interval was higher in HD and CKD-4 patients with higher TC scores (approximately 11%), but QT interval dispersion was significantly higher in patients with TC scores >400. QT dispersion showed a linear correlation with TC scores in both groups (r = 0.899 and p < 0.0001 and r = 0.901 and p < 0.0001). Male gender, age, time (months) of uraemia, low-density lipoprotein cholesterol, albumin, calcium x phosphorus product, parathyroid hormone, and TC score are important determinants of QT dispersion. Our data show that it is possible to link dysrhythmias and cardiac calcification in uraemic patients.

Vascular access for hemodialysis: the impact on morbidity and mortality.

BACKGROUND: In chronic hemodialysis (HD), central venous catheter (CVC) use seems associated with an increased risk of death. This study, using registry data, evaluated the morbidity and mortality risk associated with the use of different permanent vascular access (VA) in a HD patient cohort. METHOD: We evaluated hospitalization and death rate in prevalent and incident HD patients recorded in the uremic registry of Campania (southern Italy) for 2001. Patients were divided into three groups: CVC, artero-venous graft (AVG) and artero-venous fistula (AVF). RESULTS: One hundred and eleven dialysis units in the Campania region (69%) provided data. A total of 2201 out of 3387 prevalent HD patients were included: 92 patients (4.2%) were on CVC, 24 patients (1.1%) were on AVG and 2085 patients (94.7%) were on AVF. In comparison with AVF, the CVC group had a greater prevalence of female gender, old age, diabetes, comorbidities, hypoalbuminemia, anemia, erythropoietin (EPO) resistance, and less frequent synthetic membrane use, but had a similar dialysis duration (hr/week). Similar data were collected in the 635 incident patients registered in 2001. During the study, in both prevalent and incident CVC patients, either hospitalization or death rates were enhanced; however, the difference in the relative risk (RR) of death disappeared after correction for age, gender, malnutrition, diabetes, hemoglobin, albumin and comorbidity. Among incident patients, survival analysis was performed in patients remaining on the same VA type throughout the follow-up period; while a similar survival between groups was demonstrated in the 1st year of follow-up, survival was worse in the CVC group during the 2nd year of follow-up; however, this difference also disappeared in the adjusted analysis. CONCLUSION: This cohort study demonstrates that in chronic dialysis patients CVC choice, with respect to AVF, is mainly associated with female gender, advanced age and worse clinical conditions at baseline, and a worst outcome in both prevalent and incident CVC patients compared to AVF patients. Hospitalization, mortality rate and RR of death increased significantly; however, differences disappeared after correction for comorbidity. Therefore, these data suggest that CVC use per se is not associated with increased mortality risks with respect to AVF.