[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.

[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.

[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.

Benign monoclonal gammopathy presenting with severe renal failure.

A patient with monoclonal gammopathy and renal failure due to kappa light chain deposition in the glomerular basement membrane is reported. After 8 months, he developed a progressive and severe renal failure requiring haemodialysis. 30 months later, the monoclonal gammopathy was unchanged. Clinical features, as well as kinetic and immunological studies, were consistent with a diagnosis of benign monoclonal gammopathy (BMG). This case suggests that the renal failure complicating a monoclonal gammopathy is not related to its malignancy.

[Immunological determination of various blood proteins in clinical nephrology]. / Dosaggio immunologico di alcune proteine sieriche nella clinica nefrologica.

The serum levels of certain proteins were determined in 130 nephropathics collected into 8 different diagnostic groups, and in 20 normal subjects considered as a control group. The purpose was mainly to assess the clinico-diagnostic interest of such a measurement in nephrological practice. The results point to its clinical usefulness, particularly in differential diagnosis. It is possible to formulate interesting physiopathological interpretations notwithstanding the limitations of the eminently clinical features of the research.