Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

AB1017 RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS) AND DUAL-ENERGY X-RAYS ABSORPTIOMETRY FOR THE EVALUATION OF BONE MINERAL DENSITY IN A PERITONEAL DIALYSIS SETTING

Background

Radiofrequency echographic multi-spectrometry (REMS) is a novel ultrasound-based technique that has shown good reliability in the assessment of bone mineral density (BMD).

Objectives

The aim of this study was to compare the performance of the REMS BMD assessment with dual-energy X-rays absorptiometry (DXA) in a cohort of patients affected by end-stage renal disease undergoing peritoneal dialysis (PD).

Methods

Consecutive patients referring to the PD clinic of our hospital were enrolled. Lumbar spine and proximal femur REMS scans were performed, and lumbar spine (anteroposterior and laterolateral) and proximal femur DXA scans were performed as well. Clinical data were extracted from medical records. The risk assessment outputs of two fracture risk algorithms (FRAX and DeFRA), calculated upon the worst BMD obtained from either technique were compared as well. Analysis of variance (ANOVA) with post hoc analysis (Bonferroni) and a two-sided Student’s t-test were used to estimate the absolute differences between groups.

Written informed consent was obtained from all participants included (protocol 1483 CESC).

Results

41 total patients were enrolled (Table 1). No significant differences were documented between the BMD T-scores measured through DXA or REMS at the proximal femur. At the lumbar spine, the DXA laterolateral T-score was not significantly different from that of REMS, while the DXA anteroposterior T-score was significantly higher than both the anteroposterior DXA and the REMS measurements (Figure 1, panel A and B). When either DXA or REMS was adopted, no significant difference in the fracture risk estimate was found for both algorithms (Figure 1, panel C and D).

Table 1.

anthropometrics, clinical and biochemical characteristics of the enrolled sample. CKD, chronic kidney disease; PTH, parathyroid hormone; ALP, alkaline phosphatase; IQR, interquartile range; VFA, vertebral fracture assessment.

Sample size (M)41 (29)Age (y)Median [IQR]62 [52-73]Height (cm)Median [IQR]170 [165-176]Body weight (Kg)Median [IQR]74 [61-83]Body mass index (Kg/m2)Median [IQR]25 [22-27.8]Disease duration – CKD (months)Median [IQR]132 [48-140]Dialysis duration (months)Median [IQR]10 [3-24]S-calcium (mg/dL)Median [IQR]9.1 [8.6-9.4]S-phosphorous (mg/dL)Median [IQR]5.4 [4.6-6.4]PTH (pg/mL)Median [IQR]31.4 [22.8-46.8]25OH Vitamin D (nmol/L)Median [IQR]53 [36-72]Patients with morphometric fractures (VFA)15%Patients with femoral fractures2.4%Total n° of morphometric fractures12Figure 1.

comparison of the mean T-scores (error bars represent 95%CI) measured with DXA and REMS at the lumbar spine (panel A), and at the femur (panel B). Comparison between the DeFRA DXA and REMS-derived outputs (panel C) and FRAX DXA and REMS-derived outputs (panel D) raw and after correction for TBS. DeFRA, FRAX-derived risk assessment tool; FRAX, Fracture Risk Assessment tool; AP, anteroposterior; LL, latero-lateral; TH, total hip; FN, femoral neck; TBS, trabecular bone score.

Conclusion

Our data showed a good agreement, in a real-life PD setting, between the DXA and REMS-derived BMDs and in the consequent fracture risk assessment obtained with the FRAX or DeFRA tools.

Disclosure of Interests

Angelo Fassio: None declared, Stefano Andreola: None declared, Davide Gatti Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Consultant of: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Matteo Gatti: None declared, Giovanni Gambaro Speakers bureau: Vifor Pharma, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Ombretta Viapiana: None declared, Giulia Zanetti: None declared, Francesca Pistillo: None declared, Valeri Messina: None declared, Giovanni Adami: None declared

AB1018 RELATIONSHIP BETWEEN AORTIC CALCIFICATIONS AND DXA AND RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS) ACQUISITIONS

Background

Data on the relationship between peritoneal dialysis (PD), BMD and aortic calcifications (AOC) are lacking.

Objectives

to study the relationship between the degree of AOC and DXA and Radiofrequency Echographic Multi-Spectrometry (REMS) acquisitions.

Methods

Consecutive patients referring to the PD our clinic were enrolled. Lumbar spine (LS) and proximal femur REMS scans were performed, and LS (anteroposterior and laterolateral) and proximal femur DXA scans were performed as well. The degree of AOC was assessed through the semiquantitative score described by Kauppila et al, and applied to the laterolateral LS DXA scans. To test for correlations between different variables, we used the Pearson’s correlation for continuous variables and Spearman’s rho for discrete variables. Multiple regression analysis was performed to adjust for age and body mass index (BMI) the correlation between BMD and the CKD duration. Written informed consent was obtained from all participants (protocol 1483CESC).

Results

41 total patients were enrolled (29 males, 19 females). Median disease duration of CKD [IQR]: 132 months [48-140]. 15% had vertebral fractures at the DXA Vertebral Fracture Assessment (VFA). The median calcification score [IQR] was 2 [0-6] (min-max 0-20).

We found a statistically significant positive correlation of moderate strength between the total calcification score and the difference between the DXA AP T-score and the DXA LL T-score at the LS (p<0.01, Spearman’s rho = 0.402), Figure 1.

Figure 1.

scatter plot reporting the relationship between the difference between the AP and LL T-scores and the aortic calcifications score.

After adjustment for confounders, we found a significant negative between the LS and femoral neck BMD measured through REMS and CKD duration (Table 1). The same correlation was not significant then BMD was assessed with DXA.

Table 1.

multiple linear regression analysis for REMS T-score at each site after adjustment for age and BMI. BMI, body mass index; β, standardised coefficient.

REMS lumbar spine T-scoreβpCKD duration (months)-0.2280.035Age (years)-0.511<0.01BMI (kg/m2)0.566<0.01REMS femoral neck T-scoreβpCKD duration (months)-0.2100.04Age (years)-0.612<0.01BMI (kg/m2)0.484<0.01REMS total hip T-scoreβpCKD duration (months)-0.1530.219Age (years)-0.523<0.01BMI (kg/m2)0.560<0.01

Conclusion

Our study confirmed that the overestimation of DXA BMD assessed with the anteroposterior scan is indeed influenced by AOC. Furthermore, our data suggest that REMS might be an interesting tool for the investigation of bone changes in CKD.

Disclosure of Interests

Angelo Fassio: None declared, Stefano Andreola: None declared, Davide Gatti Speakers bureau: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB, Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB, Matteo Gatti: None declared, Giovanni Gambaro Speakers bureau: Vitor Pharma, Ombretta Viapiana: None declared, Valeri Messina: None declared, Giulia Zanetti: None declared, Francesca Pistillo: None declared, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Giovanni Adami: None declared

Association between peripheral arterial disease and cardiovascular risk factors: role of ultrasonography versus ankle-brachial index

OBJECTIVE

Most studies on atherosclerotic processes include peripheral arterial disease diagnosis only if patients report symptoms suggestive of peripheral arterial disease and/or an instrumental demonstration of lower limbs perfusion deficit is provided, rather than the sole presence of atherosclerotic lesions localized at lower limbs, this attitude leading to ignore early stages of the disease. To overcome these limitations, we have proposed a new ultrasonographic semiquantitative score to better identify all disease stages. The aim of this study is to compare ultrasonography versus ankle-brachial index in the association between peripheral arterial disease and cardiovascular risk factors.

PATIENTS AND METHODS

This cross-sectional observational study included subjects undergoing lower limbs evaluation through ultrasonography and ankle-brachial index determination because of symptoms suggestive of peripheral arterial disease or presence of known cardiovascular risk factors. Associations between ultrasonography and ankle-brachial index with cardiovascular risk factors were assessed by first fitting logistic regression models and then comparing the respective areas under the Receiver Operating Characteristic and 95% confidence intervals.

RESULTS

The areas under the Receiver Operating Characteristic for each cardiovascular risk factors were consistently larger in magnitude for ultrasonography compared with ankle-brachial index, this comparison being statistically significant for age, male gender, smoking status, hypertension, diabetes mellitus and previous cardiovascular events.

CONCLUSIONS

Our study demonstrates that ultrasonography is a better method to screen peripheral arterial disease respect to ankle-brachial index in order to identify all disease stages. These findings are useful in particular when including peripheral arterial disease as organ damage marker in cardiovascular risk stratification.

Concurrent Chemotherapy with Carboplatin + 5-Fluorouracil and Radiotherapy in Advanced Squamous Cell Head and Neck Carcinoma: A Retrospective Single Institution's Study

Aims and backround

The purpose of the study was to analyze the long-term follow-up of a single institution's experience with a regimen of concomitant carboplatin + 5-fluorouracil (CBDCA + 5-FU) infusion and radiotherapy.

Study design

Fifty-eight patients with locally advanced squamous cell head and neck cancer treated with combined chemoradiotherapy between March 1990 and October 1998 were reviewed retrospectively. According to the TNM tumor staging, 6 patients had stage II, 21 stage III and 31 stage IV tumors. The chemotherapy regimen consisted of the combination of 5-FU and CBDCA, for a total of 3 cycles. Both drugs were given as 4-day continuous intravenous infusions during the first and fourth week of radiation therapy: 5-FU at 1000 mg/m2 per day and CBDCA at 75 mg/m2 per day. Radiation was given in single daily fractions of 1.8 to 2 Gy, to a total dose of 66 to 70 Gy.

Results

After the completion of chemotherapy and radiotherapy, 34 patients (58.6%) achieved clinical and radiological (computerized tomography and/or magnetic resonance imaging) complete remission, 15 patients (25.9%) partial remission >50%, 5 patients (8.6%) partial remission >50%, and 4 patients (6.8%) had no response. Toxicity was intensive but tolerable. After a median follow-up of 25 months, overall survival and recurrence-free survival estimated for the whole patient population was 52% at 3 years, and the median length of recurrence-free survival was 23 months.

Conclusions

Our regimen combining standard single daily fraction radiation with the conventional dose of CBDCA and 5-FU was given without dose modification regardless of the severity of the adverse effects. It gave a clinical complete response at the primary site in 58.6% of patients. With a 52% projected 3-year overall survival, our series compares favorably with similar studies in the literature. Therefore, our results with concomitant CBDCA/5-FU infusion and radiotherapy are encouraging and suggest that CBDCA can be substituted for cisplatin with a good therapeutic index.

A London experience 1995-2012: demographic, dietary and biochemical characteristics of a large adult cohort of patients with renal stone disease

BACKGROUND

Kidney stone disease has an estimated prevalence of around 10%. Genetic as well as environmental factors are thought to play an important role in the pathogenesis of renal stones.

AIM

The aim of our study was to analyse and report the main characteristics of patients with kidney stones attending a large UK metabolic stone clinic in London between 1995 and 2012.

DESIGN

A cross-sectional study.

METHODS

Analysis of data from stone formers attending the University College and Royal Free Hospitals' metabolic stone clinic from 1995 to 2012. Demographic, clinical, dietary and biochemical characteristics have been summarized and analysed for men and women separately; trends over time have also been analysed.

RESULTS

Of the 2861 patients included in the analysis, 2016 (70%) were men with an average age of 47 years (range 18-87 years) and median duration of disease of 6 years (range 0-60 years). The prevalence of low urine volume, hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was 5.6%, 38%, 7.9%, 18% and 23%, respectively. The prevalence of several risk factors for stones increased over time. The majority of stones were mixed, with around 90% composed of calcium salts in varying proportion.

CONCLUSION

Our findings in a large cohort of patients attending a London-based stone clinic over the past 20 years show differences in distributions of risk factors for stones for men and women, as well as metabolic profiles and stone composition. The impact of most risk factors for stones appeared to change over time.

A genome-wide association study of anorexia nervosa

Anorexia nervosa (AN) is a complex and heritable eating disorder characterized by dangerously low body weight. Neither candidate gene studies nor an initial genome-wide association study (GWAS) have yielded significant and replicated results. We performed a GWAS in 2907 cases with AN from 14 countries (15 sites) and 14 860 ancestrally matched controls as part of the Genetic Consortium for AN (GCAN) and the Wellcome Trust Case Control Consortium 3 (WTCCC3). Individual association analyses were conducted in each stratum and meta-analyzed across all 15 discovery data sets. Seventy-six (72 independent) single nucleotide polymorphisms were taken forward for in silico (two data sets) or de novo (13 data sets) replication genotyping in 2677 independent AN cases and 8629 European ancestry controls along with 458 AN cases and 421 controls from Japan. The final global meta-analysis across discovery and replication data sets comprised 5551 AN cases and 21 080 controls. AN subtype analyses (1606 AN restricting; 1445 AN binge-purge) were performed. No findings reached genome-wide significance. Two intronic variants were suggestively associated: rs9839776 (P=3.01 × 10(-7)) in SOX2OT and rs17030795 (P=5.84 × 10(-6)) in PPP3CA. Two additional signals were specific to Europeans: rs1523921 (P=5.76 × 10(-)(6)) between CUL3 and FAM124B and rs1886797 (P=8.05 × 10(-)(6)) near SPATA13. Comparing discovery with replication results, 76% of the effects were in the same direction, an observation highly unlikely to be due to chance (P=4 × 10(-6)), strongly suggesting that true findings exist but our sample, the largest yet reported, was underpowered for their detection. The accrual of large genotyped AN case-control samples should be an immediate priority for the field.

Glycosaminoglycans, proteoglycans and sulodexide and the endothelium: biological roles and pharmacological effects

The glycocalyx is a jelly layer covering the endothelium constituted by glycosaminoglycans (GAGs), proteoglycans and adsorbed plasma proteins. This structure take part in several physiological and pathological vascular events. The glycocalyx acts as mechanosensor to shear stress and participates to regulation of vascular tone, permeability, coagulation and complement activation. Moreover it regulates the interaction and activation of blood cells with endothelial cells. The presence of a thick, normal glycocalyx is required for physiological vascular functions, whereas these functions are impaired by its damage by noxious agents. Indeed, glycocalyx alterations are involved in the pathogenesis of atherosclerosis, ischemia-reperfusion and diabetic vascular complications. GAGs such as sulodexide are promising agents to control endothelial dysfunction. They act at multiple levels: they promote glycocalyx reconstitution, control glycocalyx degrading enzymes, exert anti-inflammatory effects and have anti-apoptotic and anti-senescence effects on endothelial cells. Clinical studies support the evidence that glycosaminoglycans are useful to restore a normal endothelial function.

Temporal trend of cadmium exposure in the United States population suggests gender specificities

BACKGROUND

Over the years, environmental cadmium exposure has been linked to increased mortality. Over the years, the use of cadmium has generally decreased.

AIMS

Although even relatively low levels of cadmium have been associated with increased mortality in the general population, whether this applies to blood cadmium is not well understood.

METHODS

The authors analysed data of the National Health and Nutrition Examination Survey to study the temporal trend of cadmium exposure in the period 1988-2006 and the risk of all-cause, cancer and cardiovascular mortality associated with blood cadmium levels.

RESULTS

Urinary cadmium decreased significantly over time in males (0.58 (0.01) mcg/g to 0.41 (0.01) mcg/g; P < 0.001) but not in females (0.71 (0.09) mcg/g to 0.63 (0.08) mcg/g; P= 0.66). All-cause mortality was significantly higher in the highest quartiles compared with the lowest quartile of blood cadmium in both males (hazard ratio 1.89, 95% confidence interval 1.22, 2.89; P= 0.005) and females (hazard ratio 2.03, 95% confidence interval 1.06, 3.89; P= 0.035) after adjustment for age, race/ethnicity, smoke status, alcohol intake, annual household income and body mass index. There was also a significant association with cardiovascular mortality in females (P= 0.025).

CONCLUSIONS

Our data show that elevated blood cadmium levels are associated with elevated mortality, that there seem to be gender differences in temporal trends of cadmium exposure and that blood cadmium is a proxy of chronic cadmium exposure.

A New Proposed Protocol to Evaluate Anxiety, Depression and the Needs of Cancer Patients

Aims:

To examine the perceived needs by patients and radiotherapists using a modified by us version of the Camberwell Assessment of Need (CAN).

Methods:

We eliminated 4/22 areas of the CAN scale -ideated for psychotic patients- in order to adapt it to oncological subjects (naming it CANo). Each of the scale areas values: the existence of a specific need; the help received from care-givers; the help coming from social services; the completeness of the help received. CANo was administrated to 30 solid cancer subjects consecutively admitted in 2007 to the Radiotherapy Department of Novara Hospital (Italy), and to their respective treating radiotherapists. Patients with cognitive impairment were excluded. Patients were also administrated the following protocol: HADS (Hospital anxiety and depression scale); Paykel's list of stressful events; MBTI (Mayer-Briggs Type Indicator); EORTC QLQ-C30.

Results:

Anxiety and depression occurred at any level in 15/30 of cases. There was a significant correlation (Spearman coefficient: SC) between the numbers of needs on CANo scale and anxiety (SC:0.4; p=0.002) or depression (SC:0.48; p=0.006) levels. Higher scores in all functional EORTC scales corresponded to lower needs detected by CANo. Patient needs were perceived less important by patients themselves than their physicians (mean satisfied need scores: 1.87 vs. 3; unsatisfied need scores: 0.63 vs. 1.03). The staff overestimated patient physical health needs (7/30 vs 3/30), psychological distress (20/30 vs 5/30), relationship difficulties (9/30 vs 2/30), received information correctness (7/30 vs 2/30).

Conclusions:

The CANo scale may be useful to detect oncological patient needs and to improve the quality of care.

[Quality of life of the elderly patient on dialysis]

When elderly patients with end-stage renal disease start dialysis their quality of life, and particularly the emotional aspects of it, are very similar to those of age-matched controls. However, as the treatment becomes chronic the quality of life will decline not only with regard to the physical aspects (due to comorbidities) but also the emotional aspects. Dialysis-related stress episodes and the peculiar interrelationships in the dialysis facility setting may cause psychological discomfort which on the one hand reduces the patient's quality of life and on the other may unfavorably impact on the family and the health-care personnel. An integrated psychological approach involving the patient from the beginning of dialysis throughout the treatment process as well as the healthcare personnel and the family can reduce the patient's psychological discomfort, thereby improving quality of life.