[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.

[Social rehabilitation, state of the disease and quality of life. What are the parameters to evaluate rehabilitation of the patient under dialysis in the '90s?]. / Riabilitazione sociolavorativa, stato di malattia e qualità di vita. Quali indicatori per il paziente in dialisi negli anni '90?

The parameters used at present by the Piedmont Dialysis and Transplant Register to evaluate rehabilitation and quality of life of the dialyzed patients have been useful in the past, but they will no longer be so in the future, as the typology of the dialyzed patient is changing: the mean age is increasing, patients with high-risk conditions as vasculopathy and diabetes are widely accepted to the treatment. Thus, rehabilitation has to be evaluated not only from a social and professional viewpoint, but also as "illness situation" and "quality of life" and this can be done using the Karnofsky scale and the test of Spitzer: our Register needs to be implemented in the future by such evaluations, to go on giving us useful information about rehabilitation of the dialyzed patients.

[Patients with neoplastic disease or older than 80 years of age: dialysis survival]. / Pazienti con patologia neoplastica o di età superiore ad 80 anni: destino dialitico.

In several European countries, including Italy, the resident population is ageing. This process is at the basis of the progressive increase in incidence of new elderly patients starting dialysis and, to a lesser degree, of patients affected by severe comorbid conditions, such a neoplasia. The aim of the study was an analysis of the situation in Piedmont (Northern Italy, 4,400,000 inhabitants): out of 4483 new entries in 1981-1993, 192 were aged 80 years and 87 were affected by renal neoplasia or by multiple myeloma. Incidence of patients aged 80 increased throughout the period; use of high tolerance techniques increased in the meantime allowing an improvement in survival results. The high incidence of vasculopathic patients and the high rates of death from cachexia pinpoint how much still has to be done in the field of prevention, even before dialysis starts.

[Diabetes mellitus is currently one of the most frequent causes or associated causes of uremia. Data from the Piedmont registry of dialysis and transplantation (update, December 1993)]. / Il diabete mellito rappresenta attualmente una delle cause-concause più frequenti di uremia. Dati del registro piemontese di dialisi e trapianto (aggiornamento al dicembre 1993).

A regular dialytic treatment of diabetic patients is until accepted from about twenty years in many areas. Aim of this work was a retrospective analysis of main clinical and survival data of diabetic patients (diabetic nephropathy or diabetes as comorbidous factor = 659 cases) admitted for dialysis in Piedmont (Northern Italy Region about 4,400,000 inhabitants) in the period 1981-1993 (functional recovery and follow-up < 1 month excluded). A progressive increment in incidence of diabetic patients was seen mostly in the aged. At 12/31/1993, 263 of 2404 patients admitted for dialysis were diabetics (10.9%); the majority of them was treated in Hospital Centers with bicarbonate haemodialysis (54.4%), while a small group was treated with CAPD (12.9%). During the years ¿80 was seen a progressive leaving of CAPD as first choice method in this population and in the last period the orienteering is the utilization of mixed methods (diffusive-convective as first choice). As regards the survival are not prominent significant differences between this cohort and the cohort affected by vasculopathy as comorbidous factor (86.2 and 54.2% in diabetics vs 78.6 and 55.2% in patients affected by vasculopathy at 1 and 3 years--p = 0.3481; patients aged 45-64 years). In conclusion the cohort of diabetic patients represent a good marker of the clinical problems of the elder population with high clinic risk, in progressive increasing in our Region.

Are serum albumin and cholesterol reliable outcome markers in elderly dialysis patients?

Albumin and cholesterol are considered reliable outcome markers in dialysis patients; their influence, however, may also be related to non-independent factors, such as age and presence of co-morbid conditions. The aim of the study was an analysis of four outcome markers, assessed at start of dialysis: age, high risk conditions, cholesterol and albumin levels. Data were obtained from the Piedmont Dialysis and Transplantation Registry (northern Italy, about 4,400,000 inhabitants, 21 dialysis centres, open acceptance since mid-1970s, 5661 patients on file at 31 December 1992). Prevalence of albumin and cholesterol in the normal range increases with age; in each age group prevalence in the range is higher in patients at high risk. However, influence of these biochemical parameters is evident also in no-risk cohorts, thus identifying a subgroup with poorer prognosis also in the population without any identified classic risk factor. The influence of albumin, more evident in the population studied compared with cholesterol, is reflected by impaired survival of low-albumin patients (age > or = 65 high risk at 1 year: 60.7% vs 76.6%, P = 0.0052; age > or = 65 non-high risk, at 1 year: 76.5% vs 90.7%, P = 0.0001). In conclusion, albumin and cholesterol, assessed at start of dialysis, are reliable outcome markers even in elderly patients, identifying, in this high mortality cohort, a subgroup with poorer prognosis. If and how their effect may be reversed by dialysis therapy remains to be assessed.