[Early diagnosis and prevention of renal disease: collaboration between nephrologists and general practitioners]. / Diagnosi precoce e prevenzione delle nefropatie: collaborazione integrata con i medici di medicina generale.

Our outpatient clinic activity has taught us that a working relationship between general practitioners (GPs) and nephrologists may improve the definition of the diagnostic-therapeutic course for the benefit of the patient. We have therefore contacted the 7 teams comprising 104 GPs and pediatricians working in the area of the Agnelli Hospital in Pinerolo (132,000 inhabitants in 1,404 square kilometers) to assess the possibility of improving and strengthening the collaboration between GPs and nephrologists. The starting point was a direct telephone link aimed at dealing with patients' kidney problems in real time, evaluating history and clinical data, establishing the best timing of treatment, and defining the diagnostic and therapeutic options. The initiative was welcomed at all team meetings and it stimulated further requests for collaboration. One of the main requests was for simple clinical guidelines to deal with the most frequent clinical nephrological issues. This is the program we are carrying out: 1) We have established consulting hours during which GPs can call nephrologists at the hospital to discuss the best diagnostic-therapeutic approach for individual kidney patients. 2) We have identified diseases of common interest (isolated urinary abnormalities; hypertension; nephrotoxicity; abnormal renal function; chronic renal failure; urinary infections; kidney stones). 3) We have planned to draw up clinical guidelines. 4) We will discuss each draft with the team of GPs. On the basis of the gathered suggestions, we will prepare a final version of the guidelines to be sent to the GPs and pediatricians of our area.

Verapamil versus amlodipine in proteinuric non-diabetic nephropathies treated with trandolapril (VVANNTT study): design of a prospective randomized multicenter trial.

Angiotensin converting enzyme inhibitors (ACEI) are the most effective antiproteinuric agents and should be used as first-line drugs in both diabetic and non-diabetic proteinuric nephropathies. The role of calcium channel blockers (CCB) is much more controversial. In diabetic patients verapamil and diltiazem seem more effective than dihydropyridines in reducing urinary protein excretion, and have additive effects with ACEI, but little is available on chronic treatment of non-diabetic nephropathies for non-dihydropyridine CCBs. To test whether the combination of verapamil 180 mg or amlodipine 5 mg with trandolapril 2 mg reduces urinary protein excretion more than trandolapril 2 mg alone, we planned a prospective, randomized, double-blind, multicenter trial. The secondary aims are to evaluate the effects of both treatments on the selectivity of proteinuria and check their safety. Consecutive patients aged between 18 and 70 years with non-diabetic proteinuria > or =2 g/24 h and plasma creatinine < 3 mg/dl or creatinine clearance > or = 20 ml/min are asked to participate. After a four-week run-in during which previous antihypertensive therapy is withdrawn, a single dose of trandolapril 2 mg is given once a day in open conditions for four weeks. At the end of this period patients are randomly assigned to receive once a day, in a double blind fashion, either trandolapril 2 mg and verapamil 180 mg [plus a placebo], or trandolapril 2 mg plus amlodipine 5 mg. They are monitored after one, two, five and eight months.

[Epidemiologic analysis of the incidence of new diabetic patients on dialysis as a basis for a clinical study]. / Analisi epidemiologica dell'incidenza dei nuovi ingressi diabetici in dialisi come base per uno studio clinico mirato.

BACKGROUND: Aim of this study is to analyse the incidence of diabetic patients starting dialysis in Piedmont (Italy) during the period 1981-1996 and to evaluate, in a subgroup of patients, the causes of uremia (diabetic nephropathy or other), and the type and seriousness of comorbid factors, in order to define the clinical conditions and try to explain the causes incidence increase. METHODS: Data are taken from the RPDT (Regional Registry of Dialysis and Transplantation of Piedmont). RESULTS: Total incidence of new patients starting dialysis in this Region increased from 65 pmp in 1981-1982 to 116 pmp in 1995-1996 and the mean age increased from 55.4 +/- 15.5 years in 1981-1982 to 61.5 +/- 15.6 in 1995-1996; 49% of patients had at least one of the 13 conditions of comorbidity considered by the Registry (including severe vascular, cardiac, systemic diseases and diabetes). In the same period the incidence of diabetic patients increased from 6 pmp (1981-1982) to 19 for males and 12 pmp for females (1995-1996); this increase is higher for males and limited to patients with age > or = 60 years (for example: group 70-79 years from 7 to 56 pmp). A study performed in a group of 64 patients (52 type 2 and 12 type 1) showed the incidence of multiple comorbid factors: the most important in type 2 are vascular diseases (44/52) and heart diseases (20/52); blindness and amputations are relatively rare (2 each). An important comorbid factor in type 1 diabetes is blindness (3/12) and in this group the most frequent cause of uremia is diabetic nephropathy (DN) (9/12); in the group of type 2 patients nephroangiosclerosis and a clinical picture of progressive renal failure, without nephrotic syndrome, represents 48% of all diagnoses. CONCLUSIONS: These results underline the necessity of a strict collaboration with diabetologists and of an improvement of dedicated structures in order to meet the increase of this critical population.

[Maintenance of the tunnel and skin exit site of peritoneal catheters. Current situation and orientation of the dialysis centers of the Piedmont and the Valle d'Aosta]. / Manutenzione del tramite e dell'emergenza cutanea del catetere peritoneale. Situazione attuale ed orientamenti nei centri dialisi del Piemonte e della Valle d'Aosta.

A questionnaire was sent to the 23 Dialysis Centers of the Piedmont and Aosta Valley Regions to probe present trend on the choice of peritoneal catheter, its setting, the tunnel conformation, the first use and its maintenance. The nephrologists attach great importance to a well fixed subcutaneous tract of the catheter: this goal is obtained with wide use of pre-molded catheters, often with long and curvilinear tunnel. Avoiding an early use of the catheter and the choice of small volumes in the first weeks will permit an efficient stability of the cuff and the reduction of the risk of leakage. The choice in maintenance and monitoring of the exit-site are various and it often has a protection covering; clinical controls are made on a monthly basis.

[Urinary tract infection prevention in catheterized patients. Prevalence National Study: preliminary studies at the Pinerolo Hospital]. / Prevenzione infezioni vie urinarie (IVU) nei pazienti cateterizzati. Studio Nazionale di Prevalenza: risultati preliminari dell'Ospedale di Pinerolo.

Urinary tract infection incidence can be a possible indicator of the quality of health care in hospital. It is now clear that some kind of health care, practice and particular organizational and structural orders change the risk of UTI during hospitalizations. One third of hospital infections can be prevented by carrying out specified rules and guidelines. About 80% of UTI are a consequence of bladder catheterism. According to Major Health Institute, our Hospital takes part in a Study Group on the incidence and prevention of UTI related to bladder catheterism. Preliminary results show how much surgery activity still weighs in the cases of necessity of catheterism. Differently, urinary retention and incontinence and diuresis monitoring have a minor incidence. However the incidence of UTI after bladder catheterism is very high in our study (until 85%) also and hence the subsequent necessary antimicrobical therapy.

[Utilization of EPO in CAPD]. / Utilizzo dell'EPO in CAPD.

From January 1988 to September 1990 14 uremic patients in CAPD underwent EPO therapy in the Nephrology and Dialysis Unit of the "E. Agnelli" Hospital in Pinerolo. Intravenous routes were used in 5 patients and subcutaneous routes in the remaining 9 patients, with a unified dose of 4000 IU/three times a week. Both methods were equally efficacious in achieving the set target: partial correction of anemia together with an improvement in the patients' well-being. The most frequent side-effect was increased blood pressure, above all in those patients with pre-existing hypertension. Satisfactory control was achieved by adjusting anti-hypertensive therapy. Low EPO doses, administered via a subcutaneous route once and twice a week (mean dose: 61.6 +/- 35.8 IU/kg/week), allowed hemoglobin values to be maintained at previous levels. On these grounds the method could also be used for patients in hemodialysis.

Treatment of anaemia in CAPD patients with recombinant human erythropoietin.

EPO is an effective therapy of anaemia in CAPD patients. Monitoring serum iron level during EPO therapy is essential. Hypertension is frequently seen in patients with EPO therapy.