[Hospital-primary care teamwork in nephrology: 'preventive' epidemiology of diabetic nephropathy]. / Integrazione ospedale-territtorio in nefrologia: epidemiologia "preventiva" della nefropatia diabetica.

BACKGROUND: The onset of clinical proteinuria in patients with diabetic nephropathy usually marks the existence of irreversible and progressive kidney damage. Prevention of chronic renal failure ought to take place in earlier stages, mostly in the outpatient setting and in close collaboration with general practitioners (GPs). This study aims to evaluate the prevalence and the clinical stage of diabetic nephropathy and to screen for progression factors in the regional community referred to the outpatient department of the nephrology unit of the Mons. DiMiccoli Hospital in Barletta; it is intended as the first phase of a collaborative project for the prevention of diabetic nephropathy. METHODS: Our team asked for the collaboration of GPs within the geographic area referring to our outpatient department. This led to the institution of a working group aimed at interrelating primary with hospital care in the setting of nephrology. The clinical data of diabetic patients as well as their codified personal data were classified by GPs and subsequently processed by the nephrology team. The glomerular filtration rate was estimated by means of the abbreviated MDRD study equation. Finally, the cumulative prevalence of known risk factors for diabetic nephropathy progression was assessed in a subgroup of 201 diabetic patients. RESULTS: Within the whole group of screened subjects from the regional community (21,314), the prevalence of diabetes was 3.54%, and the rates of personal and clinical features did not show any substantial differences from the ones recorded in Italy as a whole. In the subgroup of 201 diabetic patients, the cumulative frequency of progression factors for diabetic nephropathy showed a relevant percentage of subjects with clinical and laboratory features deviating from the targets proposed by current guidelines, thus justifying the adoption of specific prevention plans. CONCLUSIONS: This study shows the feasibility and the advantages of setting up a stable collaboration between hospital and primary care in order to improve the diagnosis and prevention of kidney disease. Identification of the most frequently deviant progression factors provides the primary target for the prevention of kidney damage in diabetic patients.

[Evaluation of outpatient referral to the nephrologist]. / Valutazione del Referral nefrologico ambulatoriale.

BACKGROUND: Late referral to the nephrologist has been mainly examined to assess its causes and effects in patients with chronic renal failure. It has not been analyzed as a phenomenon in itself, to identify its features and allow more effective prevention plans. This study proposes a methodological approach to the study of outpatient referral to the nephrologist (ORN) by defining a number of evaluation tools. METHODS: Patients referred to an outpatient nephrology department represent a cohort of selected subjects on the basis of patient-related factors (clinical, social and cultural) and care-related factors. The incidence and prevalence of kidney disease in this population cannot be considered as a measure of the frequency in the general population. They may represent a first-level approach to the study of ORN by providing an indication of its pattern but not of its actual size in the catchment area. For this purpose we implemented a "referral index", calculated as the percent ratio between the number of affected subjects attending our outpatient department and the number of affected subjects within the whole catchment area. RESULTS: The number of subjects attending our outpatient department showed a progressive increase, especially among diabetics, in the last 8 years, in concomitance with a collaborative prevention project involving general practitioners. The referral index of the most frequent chronic kidney diseases in 2005 never exceeded 4.9%, accounting for the steady increase in outpatients following our ORN promotion policy. Prevalence on the one hand and referral index on the other provide different types of information about the same subgroup of outpatients: among patients with chronic kidney diseases, prevalence shows a different graduation of ORN than the referral index. Finally, the frequency distribution of chronic kidney disease stages calculated with the referral index moved toward the fourth and fifth stages rather than the second and third stages, as shown by the prevalence. CONCLUSIONS: The incidence and prevalence of renal diseases among outpatients are measures of ORN and they are useful for a qualitative analysis, such as to assess its pattern. The referral index provides a quantitative evaluation of ORN with respect to the general population of the catchment area.

[A tricky issue for the ultrasound technician]. / Un rompicapo per l'ecografista.

A 72-year-old woman presented with chronic renal failure and diffuse abdominal pain. On ultrasonography the right kidney showed an uncommon site, whereas the left kidney presented a pseudo mass on its lower pole. MRI detected a multiple anatomic anomaly: dislocation of the right kidney, renal fusion, malrotation of the left kidney. This anatomic anomaly is called ''sigmoid kidney'': it can be asymptomatic or result in genitourinary diseases.