Vascular access for hemodialysis in Italy: What a national survey reveals

BACKGROUND

Since in Italy there are no official data on vascular access (VA) for hemodialysis the Vascular Access Project Group (VAPG) of the Italian Society of Nephrology (SIN) designed a national survey.

METHODS

A 35-question survey was designed and sent it to the Italian facilities through the SIN website. The basic questions were the prevalence, the location, and the surveillance of VA, the bedside use of ultrasound, the use of fluoroscopy for central venous catheter (CVC) placement, and of buttonhole technique, the role of nephrologist in the access creation.

RESULT

The questionnaire was completed in June 2022 by 161 facilities. The survey registered 15,499 patients, approximately one-third of the Italian dialysis population. The prevalence of arteriovenous fistula (AVF), arteriovenous Graft (AVG), and CVC were 61.8%, 3.7%, and 34.5% respectively. The AVF location was 50% in distal forearm, 20% in meanproximal forearm, 30% in upper arm. For AVF creation, nephrologists were involved in 72% of facilities while for CVC placement in 62%. As regards VA monitoring, 21% of the facilities did not have a surveillance protocol; 60% did not register AVF thrombosis and 53% did not register CVC infections. Most of facilities use the fluoroscope during CVC placement, 37% when needed, and 22% never. Ultrasound-guided puncture of complex AVFs was used by 80% of facilities. Buttonhole puncture was used in 5% of patients.

CONCLUSIONS

Some considerations emerge from the survey data: (1) The increasing CVC prevalence compared to DOPPS 5 study. (2) The low rate of AVG prevalence. (3) The nephrologist is the operator in many VA procedures. (4) The fluoroscopy for CVC placement and the US-guide puncture of the complex AVF are widely used in most facilities. (5) The practice of the buttonhole is not widespread. (6) When the operator is the nephrologist more distal fistulas are performed.

Gender Disparities in Vascular Access and One-Year Mortality among Incident Hemodialysis Patients: An Epidemiological Study in Lazio Region, Italy

(1) Background: Interest in gender disparities in epidemiology, clinical features, prognosis and health care in chronic kidney disease patients is increasing. Aims of the study were to evaluate the association between gender and vascular access (arteriovenous fistula (AVF) or central venous catheter (CVC)) used at the start of hemodialysis (HD) and to investigate the association between gender and 1-year mortality. (2) Methods: The study includes 9068 adult chronic HD patients (64.7% males) registered in the Lazio Regional Dialysis Register (January 2008–December 2018). Multivariable logistic regression models were used to investigate the associations between gender and type of vascular access (AVF vs. CVC) and between gender and 1-year mortality. Interactions between gender and socio-demographic and clinical variables were tested adding the interaction terms in the final model. (3) Results: Females were older, had lower educational level and lower rate of self-sufficiency compared to males. Overall, CVC was used in 51.2% of patients. Females were less likely to use AVF for HD initiation than males. 1354 out of 8215 (16.5%) individuals died at the end of the follow-up period. Interaction term between gender and vascular access was significant in the adjusted model. From stratified analyses by vascular access, OR female vs. male (AVF) = 0.65; 95% CI 0.48–0.87 and OR female vs. male (CVC) = 0.88; 95% CI 0.75–1.04 were found. (4) Conclusions: This prospective population-based cohort study in a large Italian Region showed that in females starting chronic HD AVF was less common respect to men. The better 1-year survival of females is more evident among those women with AVF. Reducing gender disparity in access to AVF represents a key point in the management of HD patients.

Determinants of venous catheter hemodialysis onset and subsequent switch to arteriovenous fistula: An epidemiological study in Lazio region

BACKGROUND

The factors associated with the inability to start hemodialysis with an arteriovenous fistula (AVF) in chronic kidney disease patients are not fully understood.

AIM

Evaluating factors associated with type of vascular access at the first chronic hemodialysis and at 1 year after it.

METHODS

The study cohort includes patients registered in the Regional Dialysis and Transplant Registry of Lazio undergoing first hemodialysis between 2008 and 2015. Logistic regression models were used to evaluate the association between socio-demographic, clinical and care/organizational factors, and vascular access at first hemodialysis. Cox regression models were used to assess the odds of switching to AVF during the first year of hemodialysis among patients starting dialysis with central venous catheter (CVC).

RESULTS

In the cohort of 6208 incident hemodialysis patients, 52.7% had an AVF and 47.3% had a CVC. Among the 2939 incident patients with CVC, 27.4% switched to FAV after 1 year. A higher probability of starting dialysis with AVF was observed among males (OR = 1.83; 95% CI 1.63-2.06), while a lower probability was observed among patients aged >85 years (OR 0.64; IC 95% 0.51-0.80). Patients with early referral to a nephrologist had a triple probability of start dialysis with AVF. We observed a higher odds of switch to AVF among males (HR = 1.62; 95% CI 1.40-1.89) and a lower odds among patients over 65 years.

CONCLUSION

The observed high rate of AVF at the start of hemodialysis and of the switch from CVC to AVF in the first year, although declining since 2008, is a positive outcome. However, over one-third of patients maintain the CVC as vascular access for the first year because of unmodifiable factors, such as gender, age, comorbidity. The present study suggests that logistics/management and assistance/welfare problems may contribute to the delay or lack of AVF placement in incident hemodialysis patients or within the first year of dialysis.

Parathyroid Carcinoma in a Chronic Hemodialysis Patient: Case Report and Review of the Literature

Parathyroid carcinoma is a rare disease in normal population as well as in patients with end-stage renal disease. Approximately 700 cases have been reported and, of these, 20 occurred in patients receiving chronic hemodialysis. We describe a case of parathyroid carcinoma in a 59-year-old female patient with end-stage renal disease secondary to membranous glomerulonephritis treated by hemodialysis since 1995. In September 1998, the calcium level was 12.4 mg/dl and intact parathyroid hormone serum levels were 1366 pg/ml (normal range, 25-65). A routine ultrasonographic examination of the neck revealed enlargement of two parathyroid glands, the left inferior gland being the largest and measuring 2×3×2 cm. In October 1998, resection of two parathyroid glands was performed. On the basis of histology, which documented the presence of proliferating cells arranged in sheets or in a trabecular pattern, numerous mitosis and vascular invasion, a diagnosis of parathyroid carcinoma was made.

Which is the Easiest and Safest Technique for Central venous Access? A Retrospective Survey of more than 5,400 Cases

There is an ongoing debate on the technique for central venous catheterization associated with the lowest complication rate and the highest success rate. In an attempt to better define the easiest and safest venous approach, we have reviewed our 7-year experience with 5479 central venous percutaneous punctures (by Seldinger's technique) for the insertion of short-term (n=2109), medium/long-term (n=2627) catheters, as well as double-lumen, large-bore catheters for hemodialysis and/or hemapheresis (n=743). We have analyzed the incidence of the most frequent insertion-related complications by comparing seven different venous approaches: jugular vein, low lateral approach; jugular vein, high lateral approach; jugular vein, low axial approach; subclavian vein, infraclavicular approach; subclavian vein, supraclavicular approach; external jugular vein; femoral vein.

The results of our retrospective study suggest that the ‘low lateral’ approach to the internal jugular vein, as described by Jernigan and modified according to our protocol, appears to be the easiest and safest technique for percutaneous insertion of central venous access, being characterized by the lowest incidence of accidental arterial puncture (1.2%) and malposition (0.8%), no pneumothorax, and an extremely low rate of repeated attempts (i.e. more than two punctures before successful cannulation) (3.3%). We advocate the ‘low lateral’ approach to the internal jugular vein as first-choice technique for venipuncture in both adults and children, for both short-term and long-term central venous percutaneous cannulation.

Survey on advance care planning of Italian outpatients on chronic haemodialysis

OBJECTIVES

The clinical practice guidelines published by the Renal Physicians Association (USA) recommend instituting advance care planning (ACP) for patients with end-stage renal disease. Studies on this issue are lacking in Italy. Our aim was to determine the attitudes of patients on ACP in our dialysis centre.

METHODS

We performed a cross-sectional survey. We recruited patients on maintenance haemodialysis (HD) at Hemodialysis Center of Università Cattolica del Sacro Cuore, from 1 March 2014 to 31 March 2015. The only exclusion criterion was inability to give an informed consent. Patients completed a questionnaire concerning their treatment preferences in three hypothetical disease scenarios: persistent vegetative state, advanced dementia, severe terminal illness; for each patients, we also collected clinical, functional and socioeconomic data.

RESULTS

Thirty-four HD outpatients completed the study questionnaire. The majority of respondents (85%) considered information about prognosis, health conditions and treatment options, including withdrawing dialysis, as very important and 94% of respondents considered treatment of uraemic/dialytic symptoms the most important issue. In the health scenarios provided, dialysis was the treatment least withheld. Dependence on instrumental activities of daily living (0.048) and higher Charlson Comorbidity Index scores (p=0.035) were associated with continuing dialysis in at least one scenario.

CONCLUSIONS

ACP should be tailored to patients' value, culture and preferences. A significant proportion of patients, however, do not want to be involved in end of life decisions. Frail elderly patients, in particular, are not inclined to interrupt dialysis, despite poor quality of life or a poor prognosis.

Clinical use of computational modeling for surgical planning of arteriovenous fistula for hemodialysis

BACKGROUND

Autogenous arteriovenous fistula (AVF) is the best vascular access (VA) for hemodialysis, but its creation is still a critical procedure. Physical examination, vascular mapping and doppler ultrasound (DUS) evaluation are recommended for AVF planning, but they can not provide direct indication on AVF outcome. We recently developed and validated in a clinical trial a patient-specific computational model to predict pre-operatively the blood flow volume (BFV) in AVF for different surgical configuration on the basis of demographic, clinical and DUS data. In the present investigation we tested power of prediction and usability of the computational model in routine clinical setting.

METHODS

We developed a web-based system (AVF.SIM) that integrates the computational model in a single procedure, including data collection and transfer, simulation management and data storage. A usability test on observational data was designed to compare predicted vs. measured BFV and evaluate the acceptance of the system in the clinical setting. Six Italian nephrology units were involved in the evaluation for a 6-month period that included all incident dialysis patients with indication for AVF surgery.

RESULTS

Out of the 74 patients, complete data from 60 patients were included in the final dataset. Predicted brachial BFV at 40 days after surgery showed a good correlation with measured values (in average 787 ± 306 vs. 751 ± 267 mL/min, R = 0.81, p < 0.001). For distal AVFs the mean difference (±SD) between predicted vs. measured BFV was -2.0 ± 20.9%, with 50% of predicted values in the range of 86-121% of measured BFV. Feedbacks provided by clinicians indicate that AVF.SIM is easy to use and well accepted in clinical routine, with limited additional workload.

CONCLUSIONS

Clinical use of computational modeling for AVF surgical planning can help the surgeon to select the best surgical strategy, reducing AVF early failures and complications. This approach allows individualization of VA care, with the aim to reduce the costs associated with VA dysfunction, and to improve AVF clinical outcome.

Mortality in hospitalized chronic kidney disease patients starting unplanned urgent haemodialysis

AIM

Data on the outcome of chronic kidney disease (CKD) patients who are hospitalized and start unplanned urgent haemodialysis (HD) are lacking. This prospective, longitudinal, observational study aimed to define the hospital mortality rate and associated factors in CKD patients who start unplanned urgent HD.

METHODS

Between January 2003 and December 2009, all patients with CKD who were hospitalized, diagnosed with ESRD and started unplanned urgent haemodialysis at Haemodialysis Service of the Catholic University of Rome, Italy were recruited. Exclusion criteria were: acute renal failure, prior history of dialysis, multiple organ failure, coma, and dementia. Hospital mortality rate was the primary outcome.

RESULTS

Three and hundred sixteen patients were studied: 99 died after 19.5 ± 27.3 days and 217 survived until discharge. Of these, 154 were prescribed chronic HD and 63 restored renal function. Patients who died were significantly older and had a higher Charlson Comorbidity Index score. The mortality rates were 51.1% in patients with 81-90 years, 37.8% with 71-80 years, 34.1% with 61-70 years and 13.9% with age ≤60 years. Logistic regression analysis showed that age only was an independent risk factor for all-cause mortality.

CONCLUSIONS

In CKD patients who need hospitalization and start unplanned urgent haemodialysis the mortality is very high and significantly related to age.

Functional impairment is associated with an increased risk of mortality in patients on chronic hemodialysis

BACKGROUND

Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of the present study was to determine the characteristics associated with functional impairment in chronic hemodialysis, and to evaluate if functional impairment represents a risk factor for reduced survival in chronic hemodialysis.

METHODS

All 132 chronic hemodialysis referring to the Hemodialysis Service of the Catholic University, Rome, Italy between November 2007 and May 2015 were included. All patients underwent comprehensive geriatric assessment; functional ability was estimated using two questionnaires exploring independency in bathing, dressing, toileting, transferring, continence, feeding (ADLs), and independency in using the telephone, shopping, food preparation, housekeeping, laundering, traveling, taking medications, and handling finances (IADLs). Functional impairment was diagnosed in presence of dependence in one or more ADLs/IADLs. Mood was assessed using the 30-item Geriatric Depression Scale. Logistic regression was used to evaluate factors associated with functional impairment. The association between functional impairment and survival was assessed by Cox regression.

RESULTS

ADLs impairment was present in 34 (26 %) participants, while IADLs impairment was detected in 64 (48 %) subjects. After a follow up of 90 months, 55 (42 %) patients died. In logistic regression, depressive symptoms were associated with ADLs and IADLs impairment (OR 1.12; 95 % CI = 1.02-1.23; OR 1.16; 95 % CI = 1.02-1.33; respectively). In Cox regression, ADLs impairment was associated with mortality (HR 2.47; 95 % CI-1.07-5.67) while IADLs impairment was not associated with reduced survival (HR .80; 95 % CI-.36-1.76).

CONCLUSIONS

Functional impairment is associated with depressive symptoms; also, impairment in the ADLs represents a risk factor of reduced survival in chronic hemodialysis. These associations and their potential implication should be assessed in dedicated studies.

The vascular access in the elderly: a position statement of the Vascular Access Working Group of the Italian Society of Nephrology

The incident hemodialysis (HD) population is aging, and the elderly group is the one with the most rapid increase. In this context it is important to define the factors associated with outcomes in elderly patients. The high prevalence of comorbidities, particularly diabetes mellitus, peripheral vascular disease and congestive heart failure, usually make vascular access (VA) creation more difficult. Furthermore, many of these patients may have an insufficient vasculature for fistula maturation. Finally, many fistulas may never be used due to the competing risk of death before dialysis initiation. In these cases, an arteriovenous graft and in some cases a central venous catheter become a valid alternative form of VA. Nephrologists need to know what is the most appropriate VA option in these patients. Age should not be a limiting factor when determining candidacy for arteriovenous fistula creation. The aim of this position statement, prepared by experts of the Vascular Access Working Group of the Italian Society of Nephrology, is to critically review the current evidence on VA in elderly HD patients. To this end, relevant clinical studies and recent guidelines on VA are reviewed and commented. The main advantages and potential drawbacks of the different VA modalities in the elderly patients are discussed.

Fatigue is associated with serum interleukin-6 levels and symptoms of depression in patients on chronic hemodialysis

CONTEXT

Little is known about activated immune-inflammatory pathways and interleukin-6 (IL-6) in the development of fatigue and/or depression in patients with end-stage renal disease on chronic hemodialysis (HD).

OBJECTIVES

To evaluate the possible correlation between fatigue and serum levels of IL-6 in patients on chronic HD.

METHODS

One hundred HD patients were assessed for the presence of fatigue using the SF-36 Vitality subscale and were administered the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale (HARS), the Mini-Mental State Examination (MMSE), the activities of daily living (ADL), and the instrumental activities of daily living (IADL). We also calculated the time of recovery after hemodialysis (TIRD) and the number/severity of comorbidities using the Charlson Comorbidity Index (CCI). Laboratory parameters were measured as well as serum IL-6.

RESULTS

Forty-three patients constituted the fatigued group and 57 the nonfatigued group. Age, CCI, BDI, HARS, and TIRD were significantly higher in fatigued patients than in the nonfatigued patients. Conversely, the scores of ADL, IADL, and MMSE were significantly lower in fatigued than in nonfatigued patients. Serum IL-6 levels (pg/mL) were higher in the fatigued group (5.1 ± 3.4) than in the nonfatigued group (1.6 ± 1.5; P < 0.001); serum albumin and creatinine levels were significantly lower. Twenty-six patients (26%) had no symptoms of depression (BDI score <10), and 74 patients (74%) had symptoms of depression (BDI score >9). Patients with a BDI score >9 were older; had a higher CCI; a lower MMSE; a higher TIRD; lower serum albumin, creatinine, and urea levels; and higher serum IL-6 levels. The correlation analyses showed that the score of the SF-36 Vitality subscale was associated with age, dialytic age, TIRD, ADL, IADL, CCI, BDI, HARS, MMSE, serum urea, creatinine, albumin, and IL-6 levels. On multivariate general linear model analyses, with fatigue as the dependent variable and gender as a second factor, BDI and serum IL-6 levels were independently associated with the score of the SF-36 Vitality subscale. A canonical correlation analysis was performed including in the model fatigue, BDI, and biomarkers; the correlation was 0.679 (R(2) = 0.462). Fatigue, BDI, and IL-6 among biomarkers showed the strongest association with the underlying construct (standardized canonical coefficients = -0.989, 0.015, and 0.852, respectively), thus explaining a correlation of IL-6 with both depression and fatigue.

CONCLUSION

Fatigue was significantly associated with symptoms of depression and serum IL-6 levels in patients receiving chronic HD.

Wishful Thinking: The Surprisingly Sparse Evidence for a Relationship between Oxidative Stress and Cardiovascular Disease in Hemodialysis Patients

The increased frequency of cardiovascular disease observed in hemodialysis patients is secondary to the combination of many traditional (age, male sex, hypertension, smoking, diabetes mellitus, and dyslipidemia) and novel and uremia-related (inflammation, uremic toxins, adipokine imbalance, coagulation disorders, protein-energy wasting, volume overload, endothelial dysfunction, hyperparathyroidism, and subclinical hypothyroidism) risk factors. Usually, in the latter group, oxidative stress is included. However, after decades of research, it remains essentially unknown if oxidative stress has a causative role in the development of cardiovascular disease in long-term hemodialysis patients because adequate longitudinal studies are lacking. Data deriving from cross-sectional studies suggest that biomarkers of oxidative stress are associated with cardiovascular disease prevalence. Conversely, conflicting and inconclusive results have been obtained on the association between oxidative stress and coronary artery calcification, atherosclerosis, and all-cause and cardiovascular disease-related outcome. It is desirable that further studies are conducted on this topic in the near future.

Self-reported physical activity in patients on chronic hemodialysis: correlates and barriers

BACKGROUND AND AIMS

The knowledge of the barriers that are associated with decreased physical activity (PA) in patients on chronic hemodialysis (PCH) may be of primary importance for the nephrologists. Thus, we aimed to assess the barriers associated with the absent or reduced PA in PCH of a Mediterranean country.

METHODS

Patients were invited to answer the question 'How often do you exercise during your leisure time?'. Also, patients included in the study were asked to answer questions regarding barriers to physical activity lower than desired.

RESULTS

We studied 105 patients. Forty (38.1%) patients reported to never exercise, 6 (5.7%) reported to exercise less than once/week, 4 (3.8%) once/week, 23 (21.9%) two to three times/week, 12 (11.4%) four to five times/week and 20 (19%) daily. Overall, 46 (43.8%) patients never exercised or exercised less than once/week ('inactive') and 59 (56.2%) did exercise more often ('active'). At the multivariate analysis, reduced walking ability, fatigue on the non-dialysis days, and shortness of breath were independently and negatively associated with PA. The same results were found when the reduced model of the multivariate logistic backward regression was built introducing in the model also clinical and laboratory variables.

CONCLUSION

In PCH, fatigue on the non-dialysis days, reduced walking ability, and shortness of breath are barriers independently associated to decreased PA. Knowledge about the causes and mechanisms that generate these barriers has to be acquired.

Cognitive performance is associated with left ventricular function in older chronic hemodialysis patients: result of a pilot study

BACKGROUND

Cognitive impairment is a common finding in end-stage renal disease patients on chronic hemodialysis, but data on the associated factors are still scanty.

AIMS

The present study evaluated the association between cognitive function and left ventricular systolic function in hemodialysis patients.

METHODS

We enrolled 72 patients admitted to the Hemodialysis Unit of the Catholic University, Rome. Cognitive performance was evaluated using the Mini Mental State Examination (MMSE); a cutoff of 24 was used to diagnose cognitive impairment. Left ventricular ejection fraction (LVEF) was assessed by echocardiography. Multivariable linear and logistic regressions were adopted to assess the adjusted association between cognitive performance and LVEF. Also, linear discriminant analysis was performed to ascertain the cutoff level of LVEF which best predicted cognitive impairment.

RESULTS

Cognitive impairment was found in 37 (51 %) patients. According to linear regression, MMSE was independently associated with LVEF (B = 0.06; 95 % CI = 0.01-0.12; P = 0.040). Logistic regression confirmed the inverse association between LVEF and cognitive impairment (OR = 0.87; 95 % CI = 0.78-0.98; P = 0.022). In linear discriminant analysis, the LVEF cutoff level that best predicted cognitive impairment was ≤51 %.

CONCLUSION

Cognitive impairment is a common finding in hemodialysis patients. Even mildly depressed LVEF is independently associated with cognitive impairment. This association and its potential therapeutic implications should be assessed in dedicated studies.

Ethical evaluation of risks related to living donor transplantation programs

The shortage of available cadaveric organs for transplantation and the growing demand has incresed live donation. To increase the number of transplantations from living donors, programs have been implemented to coordinate donations in direct or indirect form (cross-over, paired, and domino chain). Living donors with complex medical conditions are accepted by several transplantation programs. In this way, the number of transplants from living has exceeded that from cadaver donors in several European countries. No mortality has been reported in the case of lung, pancreas, or intestinal Living donations, but the perioperative complications range from 15% to 30% for pancreas and lung donors. In living kidney donors, the perioperative mortality is 3 per 10,000. Their frequency of end-stage renal disease does not exceed the United States rate for the general population. However, long-term follow-up studies of living donors for kidney transplantations have several limitations. The frequency of complications in live donor liver transplantation is 40%, of these, 48% are possibly life-threatening according to the Clavien classification. Residual disability, liver failure, or death has occurred in 1% of cases. The changes in live donor acceptance criteria raise ethical issues, in particular, the physician's role in evaluating and accepting the risks taken by the living donor. Some workers argue to set aside medical paternalism on behalf of the principle of donor autonomy. In this way the medical rule "primum non nocere" is overcome. Transplantation centers should reason beyond the shortage of organs and think in terms of the care for both donor and recipient.

Dietary intake of trace elements, minerals, and vitamins of patients on chronic hemodialysis

PURPOSE

We aimed to estimate dietary intakes of trace elements, minerals, and vitamins in hemodialysis patients (HDP) of three centers in one metropolitan and two urban areas of Italy.

METHODS

Daily dietary intake was assessed using a 3-day diet diary in 128 HDP.

RESULTS

Mean daily intakes of trace elements were as follows: zinc, 7.6 ± 5.4 mg; copper, 14.3 ± 11.8 mg; selenium, 28.3 ± 18.1 μg; and iron, 7.2 ± 4.1 mg (7.8 ± 2.6 mg in women, 6.9 ± 2.4 mg in men). The distribution of patients by daily intakes of trace elements showed most were under the recommended values, with the exception of copper intake, which was much higher. Mean daily intakes of minerals were as follows: magnesium, 174.4 ± 94.3 mg; phosphorus, 842.6 ± 576.8 mg; calcium, 371.8 ± 363.7 mg; potassium, 1,616.2 ± 897.3 mg; and sodium, 1,350 ± 1,281 mg. Mean daily intakes of vitamins were as follows: vitamin A, 486.1 ± 544.6 μg; vitamin B1, 0.86 ± 0.7 mg; vitamin B2, 1.1 ± 0.7 mg; vitamin B3, 13.3 ± 8.1 mg; vitamin C, 47.8 ± 50.3 mg; and vitamin E, 9.5 ± 3.6 mg. The distribution of patients by daily intakes of vitamins showed most were under the recommended values. Daily intakes of trace elements and vitamins were similar among the three centers and did not differ between dialysis and non-dialysis days.

CONCLUSIONS

Many HDP have daily dietary intakes of trace elements and vitamins below the recommended values, whereas the intake of copper is much higher.

[The Italian Registry of Vascular Access]

The Vascular Access Study Group of Italian Society of Nephrology has designed a National Register in order to create an archive that collects the data on vascular accesses more detailed than the mere indication of arteriovenous fistula with native vessels, prosthetic fistula and central venous catheter. The obstacles to such a project are represented by the absence of "uniformity" in the name of the arterovenous fistula, the difficulty in increasing the daily work of dialysis centers with another registry and finally by privacy concerns. In order to standardize the vascular accesses name the Study Group proposal is to eliminate any denomination and adopt a code-descriptive system, indicating the seat of the anastomosis (1/3 distal, middle and proximal forearm, arm or lower limb), the limb (if dominant or non-dominant), the vessels involved, the type of anastomosis and the number of interventions that the pt has undergone including the last one. In this way, uniformity and universality are guaranteed. Every aspect scribed will be a cell of a data base and can used to statistical analysis. The study group has set up a software (Gev@) in order to facilitate data storage. The software is based on a form compiled at the end of each surgical procedure. The form will then be archived in digital format thereby generating automatically the data base. The advantage of this system, is represented by the possibility of turning a routine medical procedure, namely the recording of a surgical procedure, in a data base exportable for the creation of the register. As regards the issue of privacy will be obtained the patient's consent to the processing of data and the register will be stored and managed according to the regulations in terms of privacy. In the coming months, after a time of testing, the software will be available to each italian dialisys center.

Histology and immunohistochemistry of the parathyroid glands in renal secondary hyperparathyroidism refractory to vitamin D or cinacalcet therapy

BACKGROUND

Cinacalcet is a new effective treatment of secondary hyperparathyroidism (SHPT) in hemodialysis patients (HP), but the alterations of parathyroid gland (PTG) hyperplasia determined by cinacalcet and vitamin D have not been extensively investigated in humans.

METHODS

We performed histological analyses of 94 PTGs removed from 25 HP who underwent parathyroidectomy (PTx) because of SHPT refractory to therapy with vitamin D alone (group A=13 HP and 46 PTGs) or associated with cinacalcet (group B=12 HP and 48 PTGs). The number, weight, the macroscopic cystic/hemorrhagic changes, and type of hyperplasia of PTG (nodular=NH, diffuse=DH) were assessed. In randomly selected HP of group A (4 HP and 14 PTGs) and group B (4 HP and 15 PTGs), the labeling index of cells positive to Ki-67 and TUNEL and the semiquantitative score of immunohistochemistry staining of vitamin D receptor, calcium-sensing receptor, and vascular endothelial growth factor-α (VEGF-α) were measured in the entire PTGs and in the areas with DH or NH.

RESULTS

The number and weight of single and total PTG of each HP were similar in the two groups as well as the number of PTG with macroscopic cystic/hemorrhagic areas. TUNEL, Ki-67, and VEGF-α scores were higher in NH than in DH areas.

CONCLUSION

This observational study of a highly selected population of HP, submitted to PTx because SHPT refractory to therapy, shows that the macroscopic, microscopic, and immunochemistry characteristics of PTG in HP who received or did not receive cinacalcet before PTx did not differ significantly.

P-selectin, E-selectin, and CD40L over time in chronic hemodialysis patients

The aim of this study was to measure P-selectin, E-selectin, and CD-4L levels over time in chronic hemodialysis (HD) patients. Thirty stable patients with end-stage renal failure undergoing chronic HD were included in the study. Blood samples were obtained before HD for measurement of P-selectin, E-selectin, and CD-40L. Measurements were performed at month 0 (T0), 3 (T2), 8 (T3), and 13 (T4). The levels of P-selectin, E-selectin, and CD40L were also analyzed according to the occurrence of cardiovascular disease (CVD) and to CVD-related mortality. The levels of CD40L and P-selectin changed significantly over time, decreasing at month 3 and 6 and returning at the T0 levels at month 13. Conversely, E-selectin levels did not. The levels of CD40L, P-selectin and E-selectin over time did not differ significantly between patients with age ≤ 65 or > 65 years, between patients with or without CVD, or between patients who died or who survived during the follow-up. In end-stage renal failure patients undergoing chronic HD, CD40L and P-selectin, but not E-selectin, showed a transient decrease over time, and the serum levels of these molecules were not associated with CVD or with CVD-related mortality.

Reactive oxygen metabolites (ROMs) are associated with cardiovascular disease in chronic hemodialysis patients

BACKGROUND

The aim of our study was to measure reactive oxygen metabolites (ROMs) in chronic hemodialysis (HD) patients and evaluate the possible association with cardiovascular disease (CVD) and mortality.

METHODS

We measured ROMs in 76 HD patients and correlated with CVD, cardiovascular (CV) events in the follow-up and all-cause and CVD-related mortality.

RESULTS

The levels of ROMs presented a median value of 270 (238.2-303.2) CARR U (interquartile range). We created a ROC curve (ROMs levels vs. CVD) and we identified a cut-off point of 273 CARR U. Patients with ROMs levels ≥273 CARR U were significantly older, had higher C-reactive protein levels and lower creatinine concentrations. The prevalence of CVD was higher in patients with ROMs levels ≥273 (87.1%) than in those with ROMs levels <273 CARR U (17.7%; p<0.0001). ROMs levels were significantly higher in patients with CVD (317±63.8) than in those without (242.7±49.1; p<0.0001). At multiple regression analysis, age, creatinine and C-reactive protein were independent factors associated with ROMs. At multiple logistic regression analysis the association between ROMs and CVD was independent (OR: 1.02, 95% CI: 1.00-1.05; p=0.03). Twenty six patients developed cardiovascular (CV) events during the follow-up. Of these, seven were in the group with ROMs levels <273 CARR U and 19 in the group with ROMs levels ≥273 CARR U. The logistic regression analysis showed that both age (OR: 1.06, 95% CI: 1.01-1.12; p=0.013) and ROMs levels (OR: 1.10, 95% CI: 1.00-1.02; p=0.045) were independently associated with CV events in the follow-up.

CONCLUSIONS

ROMs are independently associated with CVD and predict CV events in chronic HD patients.

Fatigue in chronic dialysis patients

Fatigue is common in chronic hemodialysis (HD) patients and impacts on daily living, impairs significantly the quality of life, increases the risk of cardiovascular events and negatively influences survival. Although numerous social, demographic, clinical, and laboratory variables have been associated with fatigue, the causes of this symptom are often unclear. In the absence of an underlying, treatable disorder, the results of therapeutic intervention are typically frustrating. So far, none of the drugs tested can be recommended for preventing and treating fatigue in chronic HD patients. There is some evidence that exercise may significantly improve fatigue in dialysis patients; however, this requires confirmation through large, prospective, randomized studies.

Mini Mental State Examination over time in chronic hemodialysis patients

OBJECTIVE

Cognitive impairment is relatively common in end-stage renal disease patients on chronic hemodialysis, but the course of cognitive function deterioration in hemodialysis patients is essentially unknown. The present study aimed to evaluate if changes in Mini Mental State Examination (MMSE) over time in hemodialysis (HDP) and elderly (EP) patients differ significantly and determine the variables associated with such possible changes.

METHODS

In 80 HDP and 160 EP, the MMSE was assessed at baseline and after 1 year. Patients were stratified at baseline and at 1 year into three groups according to the MMSE: normal cognitive function >23; mild-moderate cognitive dysfunction: 18-23; severe cognitive dysfunction: <18. Univariate and multivariate analyses were performed to determine the variables associated with MMSE change over time

RESULTS

One-year median reduction of MMSE was greater in HDP (from 24 to 21) than in EP (from 26 to 25) (P<.0001). A higher percentage of HDP than EP switched from normal to mild-moderate or severe MMSE group (P<.0001). At baseline, MMSE was negatively correlated with hypertension (P=.013), angina (P=.007) and Beck Depression Inventory (P=.041) and positively correlated with education (P=.017) and male gender (P=.015). No factors were found to be significantly associated with change of MMSE between baseline and month 12 in HDP.

CONCLUSION

One-year MMSE reduction was greater in HDP that in EP. No factors were associated with MMSE reduction in HDP. However, it remains likely that cardiovascular comorbidities and low haemoglobin levels are related to such decline.

Relationship between appetite and symptoms of depression and anxiety in patients on chronic hemodialysis

OBJECTIVE

We aimed at evaluating the association between appetite and symptoms of depression and anxiety, cognitive dysfunction, fatigue, and comorbidities in patients on hemodialysis (HD).

DESIGN

A cross-sectional study was conducted.

SETTING

The study was conducted in an outpatient HD service of a tertiary level academic hospital.

PATIENTS

A total of 90 patients on HD were evaluated for appetite (during the past week, how would you rate your appetite?), symptoms of depression (Beck Depression Inventory [BDI]) and anxiety (Hamilton Anxiety Rating Scale [HARS]), cognitive dysfunction (Mini Mental State Examination [MMSE]), and comorbidities (Charlson Comorbidity Index).

MAIN OUTCOME MEASURE

Relationship between appetite and symptoms of depression and/or anxiety, cognitive dysfunction, and comorbidities was assessed.

RESULTS

In 43 patients, the appetite was very good/good (group 1), in 22, it was fair (group 2), and in 25, it was poor/very poor (group 3). Mean and median BDI were significantly higher in group 3 as well as the percentage of patients with BDI ≥16. Mean and median HARS and the percentage of patients with HARS >13 were significantly higher in group 3. MMSE was significantly lower in group 3 as well as the percentage of patients with MMSE ≤23. Multiple linear regression analysis showed a dependence of appetite by age and BDI (P = .007 and P = .002, respectively).

CONCLUSIONS

Anorexia is associated with older age and symptoms of depression in patients on HD.

Appetite and gastrointestinal symptoms in chronic hemodialysis patients

OBJECTIVE

The aim of the present cross-sectional study was to assess the association between self-reported appetite and gastrointestinal symptoms in chronic hemodialysis patients.

DESIGN

A cross-sectional study was carried out.

SETTING

The study was carried out at an outpatient hemodialysis service center.

PATIENTS

A total of 110 patients were included in this study.

INTERVENTION

The first question of the Hemodialysis Study Appetite questionnaire was used to assess the appetite of the HD patients. The multiple-choice answers for the first question "During the past week, how would you rate your appetite?" were as follows: (1) very good, (2) good, (3) fair, (4) poor, or (5) very poor. At the same time, each patient was invited to answer the following questions: Did you have any of the following symptoms (hiccups, feeling full after a few bites of food, nausea, vomiting, indigestion, abdominal pain, bloating, and constipation) in the last 2 weeks? Are there particular foods that you used to like but now do not? Did you have changes in smell in the last 2 weeks? Did you have taste changes in the last 2 weeks?

MAIN OUTCOME MEASURE

Possible associations between appetite and gastrointestinal symptoms were assessed in this study.

RESULTS

In 52 (47.2%) HD patients, the appetite was very good or good (group A), in 28 (25.4%) fair (group B), and in 30 (27.3) poor or very poor (group C). The most frequent symptoms were bloating and constipation. The frequency of food aversion and early satiety were 23.6% and 18.2%, respectively. The frequency of changes in smell and taste were 3.6% and 7.2%, respectively. The frequency of early satiety, food aversion, changes in smell and taste was significantly higher in group C as compared with group A. Similarly, the frequency of early satiety, food aversion, and changes in taste were higher in group B than in group A. The other frequencies did not differ significantly among group A, B, and C.

CONCLUSION

Food aversion, early satiety, changes in taste and smell were significantly more frequent in HD patients with poor or very poor appetite as compared with those with good or very good appetite.

[Indications for vascular grafts as dialysis access; consensus from the Italian experience]

In Italy, the use of arteriovenous grafts (AVGs) is limited (1-4%) due to different approaches to vascular access management compared to other countries, where guidelines that may not apply to the Italian setting have been produced. Therefore, the Vascular Access Study Group of the Italian Society of Nephrology produced this position paper, providing a list of 8 recommendations built upon current guidelines. The most controversial and innovative issues of the existing guidelines have been summed up in 12 different topics. We selected 60 Italian dialysis graft experts, nephrologists and vascular surgeons (PP1SIN Study Investigators). They were asked to express their approval or disapproval on each issue, thus creating a new method to share and exchange information. Almost all agreed on specific criteria for the choice of AVG over native arteriovenous fistulas (AVF) and tunneled venous catheters (tVC) and on the necessary conditions to implant them. They did not fully agree on the use of AVG in obese patients and patients at risk of developing ischemia, as an alternative to brachiobasilic fistula with vein transposition, and in case of a poorly organized setting. When AVF is feasible, it should be preferred. AVGs are indicated when superficial veins are unavailable or to repair an AVF (bridge graft). An AVG is an alternative to tVC if the expected patient survival is long enough to allow clinical benefits. The ultimate choice of the graft type is made by the physician in charge of the surgical intervention. Antithrombotic prophylaxis may be justified in some cases.

[Vascular access for hemodialysis: recommendations of the Vascular Access Study Group of the Italian Society of Nephrology]

The Vascular Access Study Group of the Italian Society of Nephrology has scheduled four national studies regarding the choice, implantation and use of vascular access. Study topics will include 1) utilization of vascular grafts for hemodialysis; 2) indications and use of venous catheters; 3) tunneled central venous catheter infection; 4) organization of the implantation and repair of vascular access. After examining the difficulties in implementing international guidelines on vascular access in Italy and the differences in practice patterns between our and other countries (where the most important studies were published), the Study Group set out to prepare four position papers based on discussion of controversial aspects of the international guidelines by nephrologists and surgeons experienced in the Italian practice. An innovative operative method for verifying the consensus on vascular access practice patterns was used. The final aim was to write a document addressed to vascular access operators (surgeons and nephrologists) based on the consensus of experts on controversial vascular-access- related issues. The project will include yearly updates of the documents.

[Ultrasound parameter-based response to treatment with new drugs for secondary hyperparathyroidism: a retrospective analysis in a single dialysis center]

In hemodialysis patients with secondary hyperparathyroidism (SHPT) ultrasonography of the parathyroid glands allows to assess the glandular growth and to define the limits of medical treatment. The present retrospective study evaluated the relationship between parathyroid gland hyperplasia and the effectiveness of new drugs. Fifty-three patients with SHPT (iPTH > 400 pg/mL) after treatment with oral calcitriol were included in the study. These patients underwent parathyroid ultrasonography and sequential therapy with intravenous calcitriol (first step), paracalcitol (second step), and paracalcitol + cinacalcet (third step). Patients with median PTH < 300 pg/mL during the period of therapy and follow-up were considered responders. The therapeutic response was correlated with ultrasound parameters (number of parathyroid glands, maximum longitudinal diameter, structural score, and vascular score). Four (10%) of 41 patients treated with IV calcitriol, 7 (27%) of 26 patients treated with paracalcitol, 7 (41%) of 17 patients treated with cinacalcet and paracalcitol, and 1 (20%) of 5 patients treated with cinacalcet alone were responders. ROC curve analysis showed that maximum longitudinal diameter (< 9 mm), number of parathyroid glands (< -1), structural score (< 2), and vascular score (< 2) predicted response to any treatment. New drugs (paracalcitol, cinacalcet) are more effective in SHPT than conventional ones. However, the traditional ultrasonographic cutoff for the efficacy of medical therapy remained unchanged. Thus parathyroid gland ultrasonography predicts the therapeutic response also to the new drugs.