[The status of peritoneal dialysis in Piedmont by 12/31/1997]

BACKGROUND

The aim of the study is to examine the situation of chronic uremia substitutive treatment by means of peritoneal dialysis in Piedmont on December 31, 1997 using data from the Piedmont regional dialysis and transplant register.

METHODS

Starting from the year 1981, data are reported (absolute, per million population, and according to different patient's anagraphic ages) about peritoneal dialysis prevalence and incidence; about basic nephropathies; drop-out from treatment; patient's rehabilitation; complications incidence, particularly peritonitis; patient's survival compared with survival of patients treated, during the same years with extracorporeal techniques.

RESULTS

The data demonstrate, during these years, an increase of peritoneal dialysis incidence and prevalence; patients' survival curves, compared with those of patients treated with extracorporeal techniques, are very similar during the first years of treatment and worse afterwards, but never reaching statistical significance.

CONCLUSIONS

They support Peritoneal Dialysis as a very good kind of substitutive treatment for some years, but this opinion deserves further examination and investigation on a longer period of time.

[Survival of patients starting dialysis at an advanced age in the Piedmont]

BACKGROUND

Patients starting dialysis in old age (age > 70 and > 80) in Piedmont are widely increasing: the survival curves of this group of patients can give very important information to evaluate the quality of both the delivered therapy and our very wide criteria of acceptance to the treatment. To this end, using data from the Piedmont Dialysis and Transplant Register, the survival curves of patients with age over 70 and 80, beginning dialysis in all Piedmont Dialysis Units between 1981 and 1996, have been examined.

METHODS

These curves have been considered both in a general way and according to the presence or absence of further high risk conditions; they show results better than expected and improving from 1981 to 1995.

RESULTS

If the survival curves of these patients are considered according to the kind of dialytic treatment performed, they do not show any significative difference.

CONCLUSIONS

The conclusion is drawn that these data strongly support first, the fitness of criteria of very wide acceptance to the treatment and modulated choice of the kind of dialytic treatment at present followed in Piedmont; and second, that dialysis treatment can give very good results also in elderly patients. So, it is suggested that the economic and structural difficulties of dialysis Units must not influence the nephrologist's choice towards elderly patients.

[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?]

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.

[Comorbidity factors in the dialysis registries and the experience of the Piedmontese Registry]

The parameters used at present by the Dialysis and Transplant Registries of various countries to evaluate dialyzed patients' comorbidity show great differences, mostly owing to the different epidemiological, social and racial characteristics of the studied populations. Moreover, 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 the Piedmont Registry will be implemented as follows: new fields about comorbidity for clinical (blindness, cachexy and dementia), social (smoking, alcohol and drugs addiction) and diagnostic (type of diabetes, of neoplasm, of cardiovascular problem) parameters, and questions needing dichotomic response (vasculopathy yes or no) will be added. The exact time of appearance of any risk factor will be requested, and a field for "others" risk factors will be added as well, trying to deeply identify the dialytic population not affected by any comorbidity factor. Finally, a new improved control system of the collected data will be used: our registry needs to be implemented in the future by such evaluations, to go on giving useful informations about epidemiology of the dialyzed patients.

[Clinical and epidemiologic characteristics of selected long-term survivors undergoing dialysis]

At the end of December, 1993, 389 patients treated by means of dialysis for more than 15 years were registered in the Piedmont Dialysis and Transplantation Register; among them, 183 were alive. Characteristics of these patients as age at the beginning of dialytic treatment, casual nephropathies, causes of death, high risk conditions, dialytic schedules, vascular access, hospitalization requirements, rehabilitation, dialysis efficacy, gross mortality, were compared with those of patients treated for a shorter time, concluding that a very long dialytic survival can be achieved with a good clinical and social rehabilitation.

Elderly patients on dialysis: epidemiology of an epidemic

The increase in the incidence of elderly patients starting dialysis has been as sharp, during the 1980s-1990s, as an epidemic (+70%, +150% in different settings). According to this study, performed in Piemonte, northern Italy, the process is still ongoing. During the period 1981-93, according to the Regional Registry of Dialysis and Transplantation (RPDT: data on 100% of centres and patients), the cohort on treatment increased by 79.5% and the annual incidence by 48.3%; the increase is limited to older people and is greater in males. Nephroangiosclerosis/ischaemic renal disease and diabetes mellitus are the main diagnoses. Since the increase of elderly patients is still ongoing, forecasts are difficult; according to a computer simulation, a plateau of patients on treatment is reached only if incidence is stabilized, While it is impossible to exclude a decrease in hidden selection or an increase in referral, complex modifications at the overall population level are presumably at the basis or the increase of elderly patients on dialysis. Despite the increase in average age, however, survival improved throughout the period; this confirms the interest towards the open dialysis system adopted in Piemonte, which is characterized by easy shifts among treatments and by the widespread use of high tolerance techniques.

[Helicobacter pylori in patients undergoing periodic hemodialysis]

Forty-nine haemodialyzed patients have been submitted consecutively, under informed consent, to endoscopy with multiple antral gastric mucosa biopsies for Helicobacter pylori (HP) identification, performed by urease, microscopic and cultural tests, as well as histologic examination. Patients have been considered HP negative when negative for all tests; positivity for HP has been correlated with gastritis histologically evaluated according to Whitehead; at endoscopy, blood samples for HP specific IgG, IgA, IgM have been collected; patient's life style concerning smoke, alcohol and drugs as FANS has been investigated as well. HP prevalence in our haemodialyzed patients is 38.8 per cent, similar to general population submitted to endoscopy; a statistically significant correlation between HP and gastritis and specific IgG, but no correlation between HP and age, dialysis duration, IgA, IgM, smoking, alcohol or drugs consumption has been found.

[Anti-HCV in patients undergoing dialysis in Piedmont and in Valle d'Aosta]

Special questionnaires were distributed in order to assess the current incidence of anti-HCV antibodies in Dialysis Centres in Piedmont and the Aosta Valley. The analysis of findings showed an overall positivity of 23.9%, with higher values in those cases treated with extracorporal methods and lower values in those patients treated with peritoneal dialysis. The data also confirmed the correlations between anti-HCV antibodies and the number of transfusions performed, and suggested the possible influence of previous operations, high risk manual occupation, or more than one of these factors, in addition to environmental conditions. Lastly, the paper reports the prophylactic measures currently in use for patients and medical staff in the various centres in Piedmont and the Aosta Valley.

[Quantification of treatment time in the high-efficiency dialysis method]

Precise quantification of treatment time is allowed by using the urea kinetic models for dialytic therapy prescription: the dialytic dose may be expressed by the KT/V ratio, the nutritional status by PCR. Due to dialysis disequilibrium urea extraction was significantly lower in high efficiency dialysis than in traditional schedules, suggesting to increase the KT/V value when treatment time is reduced. The comparison of KT/V and PCR values obtained by the Gotch model (single pool variable volume) with the results derived by the diagram of Keshaviah has shown significant correlation for both, confirming the usefulness of this simplified model in clinical practice.

Histomorphometric study of the dynamics of mineralization in a case of osteomalacia caused by anticonvulsants treated with 25(OH)d3

The authors describe the experimental method used to make histomorphometric determinations in a case of osteomalacia caused by anticonvulsant drugs treated with 25(OH)D3. This comprised double fluorescent markings repeated at set time intervals after taking biopsy samples from the patient. This combined method of study enabled the effect of the treatment to be monitored throughout its course.

[Course and significance of various biochemical parameters in 1,25-dihydroxyvitamin D3 therapy of uremic osteodystrophy]

Thirty-seven osteodystrophic and chronically haemodialyzed patients have been treated for 1-22 months by means of 1,25(OH)2D3. Under treatment a marked improvement of symptomatology and radiographic findings has been observed in the majority of cases; from the haematochemical viewpoint a rise of calcemia and phosphoremia, a fall in alkaline phosphatase and a variable course of PTH have been observed. Several episodes of asymptomatic hypercalcemia ceased with posology reduction; only 3 cases needed stopping the treatment for this reason, one of them definitively; 12/37 cases needed hypophosphoric diets and increase in oral aluminium hydroxide doses to control hyperphosphoremia. The Authors conclude that, to achieve a correct management of a 1,25(OH)2D3 therapy for renal osteodystrophy, is mandatory a strict and accurate biochemical control: in this way is possible to obtain an effective modulation of the posology avoiding the appearance of side-effects as hypercalcemia and ectopic calcifications.

Cimetidine does not influence cellular immunity in patients with chronic renal insufficiency

Numerical and functional markers of peripheral lymphocytes were adopted to study the influence of cimetidine on the immune response in immunocom-promized patients. Twenty-three patients on regular dialysis treatment, who had been given cimetidine (400 mg daily) for peptic ulcer, were studied during a follow-up of 3 months. Thirty healthy people served as controls for the study of the immunological parameters, i.e. DNCB and PPD skin tests, E-rosetting assays, monoclonal antibodies to T-cells, membrane immunoglobulins for the B-cells, serum immunoglobulins and complement. Before therapy was started CMI was impaired in all patients, with a significant reduction in the E-rosette count (P less than 0.01) and depressed DTH (DNCB, PPD). The number of active E-rosettes and OKT4 subsets increased slightly during the period of treatment, though this finding was not confirmed by functional in vivo tests. No change was observed in the B-lymphocyte count and in serum immunoglobulins or complement. The fact that treatment with cimetidine does not seem to influence the immune response in patients on RDT, may suggest that this therapy does not restore the principal immunopathological disorder of these patients, and further justifies its use in patients awaiting renal transplantation or in those who have been given transplant.

The influence of blood transfusion on cellular immunity

To evaluate the effect of transfusion on immunity, we studied some immunological parameters in 14 uremic patients treated with 3 blood transfusions (5 with HLA-compatible and 9 with random transfusions). Before transfusions 8/14 patients were DNCB-negative; both spontaneous and active E-rosettes were below normal range. The parameters of humoral immunity (S-Ig, C3, C4, IC, CRP) were normal. After both the first and second transfusions an increase in T- and B-lymphocytes was found. The third transfusion led to a more pronounced and prolonged immunosuppression in patients treated with compatible transfusions than in those treated with random transfusions. Our findings suggest that blood transfusion--HLA-compatible transfusion in particular--results in an impairment of the lymphocyte role.

[Quantitative and qualitative determinations and clinical and histological correlations of cryoglobulins in glomerulonephritis]

The Authors have investigated the presence of cryoglobulins in sera from 91 GN patients, 69 of whom had a renal biopsy. Cryoglobulins have been found in 12.5% of the idiopathic glomerulonephritis (GN), in 22.2% of the ones related to systemic diseases. Also 4 cases of GN with mixed essential cryoglobulinemia have been studied. Quantitative analysis has shown a IgG and IgM prevalence, the last ones of monoclonal type in 77.8% of the cases, with anti IgG activity in 44.4%. Concerning cryoglobulins found in idiopathic GN, the Authors observed a high incidence in the forms with cellular proliferation and glomerular exudation, as rapidly progressing GN, the acute post-infectious GN, and the mesangio-capillary GN. Among the GN related to systemic diseases, high incidence of cryoglobulins has been observed in lupus nephritis and polyartheritis. In both diseases (idiopathic GN and GN related to systemic diseases) a good correlation was found between clinical-ordinary activity and immunological parameters such as circulating immune complexes and complement breakdown products. The correlation between cryoglobulins level and disease activity is less evident in the mixed essential cryoglobulinemia G.N. Furthermore the Authors discuss here the pathogenesis of cryoglobulins in human G.N.

[Rosette E and active rosette E tests in the evaluation of cell-mediated immunity in uremic patients]

To evaluate cellular immunity in uremia, we studied 235 uremic patients (178 on regular hemodialysis and 57 on medical treatment). E-rosettes were significantly lower (p less than 0.01) in all patients. The active E-rosettes test was found less significant to study T lymphocyte markers. The kind of correlations made with primary disease, small molecule levels, rehabilitation, suggests that cell-mediated immunodeficiency in uremia is a premature phenomenon and scarcely influenced by adequate hemodialysis treatment.

[Semeiotic significance of the clinical use of methods of determining serum immunocomplexes in human glomerulonephritis]

The application of tests for the determination of serum immune complexes in nephrology has supplied fresh pathogenetic and symptomatological information. An account is given of results obtained in primary and secondary glomerulonephritis using four methods; the solid-phase Clq test, the polyethylene glycol precipitation test, the immunofluorescence on polymorphonucleates tests, and the solid-phase conglutinins test (with anti-IgA antibodies). The results take on a symptomatological meaning in many classes of human glomerulonephritis, both in the differentiation of primary forms and those secondary to systemic diseases, and in prognosis. A critical review is made of the data obtained in a personal series in the light of a long-term follow-up. The limits and specificity of each test are also discussed.

[Diabetic nephropathy. Review of the current status and practical considerations concerning etiopathogenetic, clinical and therapeutic aspects]

Reference is made to personal research and clinical experience, coupled with a select bibliography, in a survey of the most significant current knowledge with regard to diabetic nephropathy, designed for the nonspecialist practitioner and intended to enable him to update his knowledge without plunging into details, and to quickly decide what measures he should adopt in his daily practice. Questions of histopathology and aetiopathogenesis are examined, together with the relations between proteinuria, hypertension, renal function, and diabetic nephropathy. The clinical profile and progress of the disease are illustrated. Lastly, an account is given of the conventional modes of treatment, and of the still partly unsatisfactory results offered by more recent forms of replacement therapy (dialysis and transplantation).

[Basic aspects and current trends in iatrogenic kidney diseases. Correlations between their physiopathological mechanisms and clinical findings for the general practitioner]

Iatrogenic origins may be assigned to any form of kidney disease. Of the pathogenetic mechanisms involved, increasing importance is now attached to immunological responses and intravascular coagulopathies, though other processes long known to medicine have not ceased to play their part. Moreover, recent advances in the improvement of drugs and the standardisation of their use have given a better idea of the potential damage to the kidneys from many substances. A re-examination is made of the main findings in this field with a view to offering a simple summary of the underlying physiopathogenetic mechanisms, and drawing the diagnostic and clinical conclusions therefrom, so as to aid the general practitioner rather than the specialist. An account of the various medical interventions that may lead to kidney lesions, and the circumstances in which such interventions are most likely to be harmful, is followed by an analysis of recent opinions on the correct way of administering drugs in patients with kidney disease, so as to limit their potentially harmful effects as far as possible.

[The quarantined dialysis room for Australia-antigen-positive patients. Theoretical, normative, structural, operational, organizational and management aspects]

The technical features of dialysis facilitate the transmission of hepatitis B virus and the outbreak of possibly serious epidemics among patients and hospital staffs. Statistical, epidemiological and clinical data have been collected on many occasions. They serve to emphasise the problem and the need for quarantined centres. The establishment of such a centre for HBsAg-positive patients is discussed in the light of personal experience in the design and setting up of quarantined rooms. The underlying technical and structural requirements are also examined. Reference is also made to two years' experience in the running of a room of this kind. Stress is laid on the importance of having a room for these patients, not only from the clinical standpoint (lessening of contagion), but also from teh social and exonomic standpoint (reduced costs and length of hospital stay, greater rehabilitation).

[Home dialysis. Review of clinical organizational and management problems encountered in more than 6 years of activity]

Together with other forms of self-dialysis (including limited assistance and self-service), home dialysis keeps down cost to much lower levels than those ruling within the hospital. Self-management, which is a common factor of various types of extra-hospital dialysis, also enables the patient to fit in better to society and, in the majority of cases, offers complete working rehabilitation by way of deeper consciousness of his disease and of the various treatments for it. Personal experience of home dialysis covering 6 years activity in the sector is reported. 91 patients have been trained in self-management and 65 of these have already been sent home or are about to be. The most important problems tackled over this period are examined and the experience analysed. Particular reference is made to clinical, organizational and management problems. The paper thus forms a practical guide for those wishing to direct their efforts towards a home dialysis programme.

[Hyperparathyroidism in endocrinology and nephrology]

The literature on primary and secondary hyperparathyroidism is surveyed in the presentation of an account of the present positon. Reference is also made to personal clinical experience, particularly in secondary cases. The physiopathology of parathormone, calcitonin and vitamin D is described; the last, in fact, has proved useful in the treatment of secondary forms. The usual symptomatological tests of performance are explained, together with their diagnostic value. The clinical symptoms and their physiopathological significance are also illustrated. Stress is laid on the importance of conservative management in secondary forms. Good results now enable parathyroidectomy to be avoided or delayed in many cases.

[Modern criteria for the choice of dialysis monitors]

The tasks required of a modern dialysis monitor are explained and the parameters that it supervises are described. Ways in which the maximum degree of safety can be assured are discussed and the criteria applicable the choice of equipment for routine hospital, home and research use are indicated.