Quality of care and clinical inertia in the management of cardiovascular risk factors in patients with type 1 and type 2 diabetes: data from AMD annals.

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality among patients with diabetes, and for this reason, all guidelines for CV risk management provide the same targets in controlling traditional CV risk factors in patients with type 1 or type 2 diabetes at equal CV risk class. Aim of our study was to evaluate and compare CV risk management in patients with type 1 and type 2 diabetes included in AMD Annals Database paying particular attention to indicators of clinical inertia. METHODS: This was a multicenter, observational, retrospective study of AMD Annals Database during year 2022. Patients with diabetes were stratified on the basis of their cardiovascular risk, according to ESC-EASD guidelines. The proportion of patients not treated with lipid-lowering despite LDL cholesterol > to 100 mg/dl or the proportion of patients not treated with antihypertensive drug despite BP > 140/90 mmhg and proportion of patients with proteinuria not treated with angiotensin converting enzyme inhibitors or angiotensinogen receptor blockers (ACE/ARBs) were considered indicators of clinical inertia. The proportion of patients reaching at the same time HbA1c < 7% LDL < 70 mg/dl and BP < 130/80 mmhg were considered to have good multifactorial control. Overall quality of health care was evaluated by the Q-score. RESULTS: Using the inclusion criteria and stratifying patients by ESC/EASD Cardiovascular Risk categories, we included in the analysis 118.442 patients at High Cardiovascular risk and 416.246 patients at Very High Cardiovascular risk. The proportion of patients with good multifactorial risk factor control was extremely low in both T1D and T2D patients in each risk class. At equal risk class, the patients with T1D had lower proportion of subjects reaching HbA1c, LDL, or Blood Pressure targets. Indicators of clinical inertia were significantly higher compared with patients with T2D at equal risk class. Data regarding patients with albuminuria not treated with RAAS inhibitors were available only for those at Very High risk and showed that the proportion of patients not treated was again significantly higher in patients with T1DM. CONCLUSIONS: In conclusion, this study provides evidence of wide undertreatment of traditional cardiovascular risk factors among patients with diabetes included in AMD Annals Database. Undertreatment seems to be more pronounced in individuals with T1D compared to those with T2D and is frequently due to clinical inertia.

Recombinant tissue plasminogen activator (rt-PA) as first-line therapy for declotting of haemodialysis access.

One of the most common complication in haemodialysis patients is thrombosis of the arteriovenous fistula (AVF). Thirty-five patients with a total of 42 thromboses of the angioaccess were infused via a small needle: (i) into the feeding artery (50% of the cases); (ii) into a AVF venous segment of the arteriovenous fistula (42.8%); (iii) directly into the thrombus (7.1%), by rt-PA. After an initial pulse of 5-10 mg, according to body weight, the drug was continuously infused by a pump with the speed automatically programmed in 30 Brescia-Cimino autologous AV fistulae and 12 polytetrafluoroethylene (PTFE) grafts. A complete thrombolysis with return of bruit and thrill was obtained in 71.4% of the cases using a mean drug dose of 21 mg and an infusion time of 3.8 h. All the successful cases underwent haemodialysis via AVF on the same day. No bleeding occurred at remote sites. Local bleeding occurred in 16% of the cases; in no case was it so severe as to require the suspension of the therapy or blood transfusions. The median cumulative duration of patency after thrombolysis was 32.4 months. Respectively 21, 12 and two patients had a functioning angioaccess after 3.6, 32.4 and 36 months from the lytic approach. Failure of the treatment was not related to the patients' gender or age, AVF age, route of administration of the drug, type of vessel (natural or artificial), or delay between the discovery of the fistula occlusion and the start of the therapy. In unsuccessful cases an organic lesion of the vessels was documented by angiography or echo colour Doppler. In summary, rt-PA local infusion provides a useful means of preservation of AV fistulae and may be used as the therapy of first choice in dialysis patients without active bleeding or high bleeding risk.

Comparison of fast peritoneal equilibration tests with 1.36 and 3.86% dialysis solutions.

At present dialysis solutions with different glucose concentrations are used for the peritoneal equilibration test (PET) and Fast-PET in peritoneal dialysis (PD). We compared the results of two Fast-PETs, using 1.36 and 3.86% solutions sequentially in 30 patients on PD treatment, to obtain information on peritoneal transport (D/P-4 h) and ultrafiltration rates. Creatinine, phosphorus and urea D/P-4 h in the two Fast-PETs were not statistically different, unlike those for potassium, beta 2-microglobulin and glucose. The creatinine and phosphorus D/P-4 h values in particular proved to be uninfluenced by the different dialysis solutions. The lack of correlation between the two Fast-PET ultrafiltration values confirmed the difficulty in interpreting this parameter, above all in the case of non-homologous Fast-PETs. We obtained useful indications for comparing different Fast-PET results, but were unable to reach a decisive conclusion regarding the best of the two dialysis solutions for this test.

Alterations in erythrocyte morphology induced by blood pumps.

A scanning electron microscopy was used after in vitro and in vivo tests to investigate any alterations caused by the peristaltic roller pump in erythrocyte morphology. The electron micrographs of samples were examined as follows: 1) by image analyser; 2) by applying Bessis's classification for the qualitative study of crenated red blood cells (RBCs). The in vitro test was repeated four times using blood from healthy donors. Each basal blood sample was divided into 250 ml portions, each of which was recirculated for 12 minutes at different flow rates. In order to verify any persistent erythrocyte damage caused by the peristaltic pump, 15 minutes after recirculation at 450 ml/min, another sample was prepared using the blood remaining from the last test. A statistically significant direct correlation was found between blood flow (Qb) increase and the percentage of morphologically altered RBCs, when either using an image analyser (r = 0.97; p < 0.05) or Bessis's classification (r = 0.95; p < 0.05). However, neither method showed any statistically significant difference between the percentage of deformed RBCs, determined in the basal sample, or in the percentage found at the end of the 450 ml/min test after standing 15 minutes at room temperature. The in vivo test was carried out on 6 patients over 2 dialysis sessions, which differed only for the Qb: 250 versus 400 ml/min. The two dialysis sessions gave comparable results when using both study methods regarding the presence of deformed RBCs.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term survival on renal replacement therapy for primary hyperoxaluria type I.

We describe the case of a patient in end-stage renal failure due to primary hyperoxaluria type I (PH1) who started hemodialysis in 1977 and is still alive and active. The diagnosis of PH1 was first suspected after a bone biopsy performed in 1981 to investigate hyperparathyroidism. Oxalosis recurred as early as 3 months after transplantation in a cadaver kidney grafted in 1987; nevertheless, graft function remained good enough to make possible the discontinuation of dialysis treatment for 5 months and thereafter to have only 1 dialysis a week for 17 months. The diagnosis of PH1 has been recently confirmed despite the patient being already anuric by means of the determination of plasma oxalate and glycolate levels as well as by determining hepatic alanine:glyoxylate amino-transferase.

Influence of donor age on cadaver kidney graft function and survival: univariate and multivariate analyses.

The influence of donor age on the outcome of kidney transplantation (TX) was evaluated in 169 patients who received a primary cadaver kidney transplant at our center between September 16, 1984, and December 31, 1990. All the patients received cyclosporin A as part of the immunosuppressive protocol. Patients were grouped according to donor age: low donor age (LDA; donor age range 12-25 years), medium donor age (MDA; range 26-50 years) and higher donor age (HDA; range 51-66 years). There were no differences between groups in graft and patient survival, and multivariate analysis did not show any effect of donor age on those parameters. Proteinuria/day and number of rejection episodes did not differ between groups either. Immediate diuresis was more frequent in group LDA than in the other two groups (73.8, 54.7 and 57.1%, respectively; p < 0.05) and immediate diuresis resulted as a weak positive prognostic factor for graft outcome at multivariate analysis (p = 0.05). At both univariate and multivariate analyses, donor age resulted inversely correlated with creatinine clearance (CCr) at every period after TX but the 5th year, with r2 from 0.12 to 0.23 (p < 0.01). The LDA group had significantly better CCr than the HDA group at every period after TX but for the 5th year (the MDA group behaved intermediately).(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatitis C virus in dialysis units: a multicenter study.

Three hundred and eighty-seven chronic hemodialysis patients were evaluated, in a multicenter study, to investigate the epidemiology of hepatitis C virus. In anti-HCV seropositive patients, serum ALT values and blood transfusions were retrospectively compared; blood donors were studied for serum transaminases. In seropositive patients without previous blood transfusions, analysis of dialysis schedule was done. Eventually, the intrafamilial transmission of hepatitis C virus was studied in 104 family members. The prevalence of HCV infection in hemodialysis patients was 15.7%. The incidence of acute hepatitis was frequent, while chronic hepatitis incidence was less than expected (17.5%). Intrafamilial diffusion was low (1.9%). Blood-transfusion-related infections seem to be negligible, while cross-contamination in dialysis units seems to be very important.

Comparison between first- and second-generation test for anti-hepatitis C virus antibodies in hemodialysis patients.

The serum of 387 hemodialysis patients from 9 dialysis units was checked for anti-hepatitis C virus antibodies with a 1st-generation ELISA (Ortho) test: 61 patients were repeatedly positive. In order to avoid false-positive results, these sera were tested with a 1st-generation confirmatory RIBA test, 2nd-generation screening ELISA test and 2nd-generation confirmatory RIBA test. The 2nd-generation ELISA test confirmed data obtained with 1st-generation ELISA, however, the 1st-generation confirmatory RIBA test underestimated the number of anti-HCV-positive patients.

[Mass transfer of magnesium in hemodialysis]. / Mass-transfer del magnesio in emodialisi.

The rate of mass-transfer (MT) of magnesium during hemodialysis was studied in thirty-five patients with hypermagnesemia (Mg = 3.75 +/- 0.72 mg/dl) undergoing chronic hemodialysis. The aim of the study was to verify which is the best dialytical approach to remove the excess of magnesium. The concentration of Mg in the dialysate was of 1.82 mg/dl for all patients. MT was -0.51 +/- 0.36 g and no statistical difference was found between patients treated with cuprophan hollow fibers dialyzers, PAN and cuprophan plates. Mg MT is not correlated with dialysis duration (r = -0.23; p:ns), urea clearance (r = -0.08; p:ns), KT/V index (r = -0.03; p:ns), blood flow (r = -0.15; p:ns). In conclusion from our data, in agreement with other Authors, reduction of serum Mg levels is more convenient by obtained by a decrease in Mg concentration in the dialysate under 1.82 mg/dl, in order to increase the blood-dialysate concentration gradient.

Comparison between three mathematical models of KT/V.

In thirty anuric patients undergoing chronic hemodialysis the KT/V values obtained with the formula: (formula; see text) were compared with the values obtained with the following two formulae: (formula; see text) The results given by formulae B and C differed from those with formula A respectively by 12.81 +/- 11.98% and 10.38 +/- 3.64%. For routine determination of KT/V we suggest the use of formulae A and C as a means of establishing rapidly, in one step, whether the hemodialytic treatment examined is adequate.

[Hypopotassemia and rhabdomyolysis. Description of 3 cases of different etiologies]. / Ipopotassiemia e rabdomiolisi. Descrizione di tre casi a diversa etiologia.

Three cases of rhabdomyolysis secondary to hypopotassaemia caused respectively by excess liquorice intake, the use of a nasal spray containing fluoroprednisolone acetate and a kidney tubular condition identified as distal tubular acidosis (ATR) are described. The aetiology of each case is discussed with a description of the clinical course and laboratory tests and particular emphasis on variations in the renin-angiotensin-aldosterone system.