Hemorheology in kidney transplantation: A role for cardiovascular risk?

Uremic patients undergoing dialysis (HD) present a cardiovascular risk of death 10-20 fold higher than general population, but also kidney transplantation keeps considerable cardiovascular burden.Hemorheologic profile alterations have been described in HD; comprehensive data on kidney transplant recipients (KT) are missing. Aim of our study is to characterize the hemorheological profile in KT, and to compare these data with HD and healthy volunteers (HV).We investigated 47 HV, 90 HD and 108 KT.We confirm hemorheological alterations in HD. KT, when compared to HD, normalizes many parameters: plasma viscosity, whole blood viscosity at 1-Hz and 200-Hz shear rate, erythrocyte aggregation index and yield stress. KT show a markedly lower erythrocyte deformability (ED). We found no differences among hemorheological parameters between the different classes of immunosuppressive drugs used.In conclusion, HD show various hemorheological defects; this could support the high incidence of cardiovascular complications. KT improves most hemorheological alterations; nevertheless, ED is reduced in KT, maintaining a detrimental injury at microcirculatory level and leading to the progression of fibrosis till to end-stage injury. Impaired ED in KT could also contribute to progression of interstitial fibrosis and tubular atrophy (IF/TA) in grafts.

Acute pancreatitis associated with everolimus after kidney transplantation: a case report

Background

Acute pancreatitis (AP) following KT is a rare and often fatal complication of the early post-transplant period. Common causative factors for AP are rare after KT; anti-rejection drugs as CyA, prednisone and MMF have been implicated, although evidence is not strong and we found no reports on possible causative role for mTOR inhibitors.

Case presentation

A 55-year-old Caucasian man with end-stage renal disease due to idiopathic membrano-prolipherative glomerulonephritis underwent single kidney transplantation (KT) from cadaveric donor. Anti-rejection protocol was based on Basiliximab induction followed by prednisone and mycophenolate mophetil (MMF) and Cyclosporine; Everolimus (Eve) was scheduled to substitute MMF at week 3. At day 1 he had an asymptomatic elevation of pancreatic enzymes, spontaneously resolved. The further course was unremarkable and on day 19 he started Eve, with following asymptomatic rise in pancreatic enzymes. At day 33 the patient presented with abdominal pain and a marked elevation in serum amylase (1383 U/l) and lipase (1015 U/l), normal liver enzymes and bilirubin, no hypercalcemia, mild elevation in triglycerids; RT-PCRs for Cytomegalovirus or Epstein-Barr virus were negative. The patient had no history of alcohol abuse; ultrasound, CT and MRI found no evidence of biliary lithiasis. CT scans showed a patchy fluid collection in the pancreatic head area, consistent with idiopathic necrotizing pancreatitis. The patient was treated medically and Eve was withdrawn 1 week after. Patient underwent guided drainage of the fluid collection, but developed bacterial sepsis; surgical intervention was required with debridement of necrotic tissue, lavage and drainage; immunosuppression was totally withdrawn. Following course was complicated with multiple systemic infection. Transplantectomy for acute rejection was performed, and patient entered hemodialysis.

Conclusions

Our patient had a presentation that is consistent for a causative role of Eve. A predisposing condition (acute pancreatic insult during transplant surgery) spontaneously resolved, relapsed and evolved rapidly in AP after the initiation of treatment with Eve with a consistent time latency. None of the well-known common causative factors for AP was present. We discourage the use of Eve in patients with recent episodes of sub-clinical pancreatitis, since it may represent a precipitating factor or interfere with resolution.

Lavandula angustifolia Mill. Essential Oil Exerts Antibacterial and Anti-Inflammatory Effect in Macrophage Mediated Immune Response to Staphylococcus aureus

Different studies described the antibacterial properties of Lavandula angustifolia (Mill.) essential oil and its anti-inflammatory effects. Besides, no data exist on its ability to activate human macrophages during the innate response against Staphylococcus aureus. The discovery of promising regulators of macrophage-mediated inflammatory response, without side effects, could be useful for the prevention of, or as therapeutic remedy for, various inflammation-mediated diseases. This study investigated, by transcriptional analysis, how a L. angustifolia essential oil treatment influences the macrophage response to Staphylococcus aureus infection. The results showed that the treatment increases the phagocytic rate and stimulates the containment of intracellular bacterial replication by macrophages. Our data showed that this stimulation is coupled with expression of genes involved in reactive oxygen species production (i.e., CYBB and NCF4). Moreover, the essential oil treatment balanced the inflammatory signaling induced by S. aureus by repressing the principal pro-inflammatory cytokines and their receptors and inducing the heme oxygenase-1 gene transcription. These data showed that the L. angustifolia essential oil can stimulate the human innate macrophage response to a bacterium which is responsible for one of the most important nosocomial infection and might suggest the potential development of this plant extract as an anti-inflammatory and immune regulatory coadjutant drug.

Hemorheologic alterations in peritoneal dialysis

Dialysis patients present a cardiovascular risk substantially higher than general population, due to both traditional and non-traditional risk factors. Hemorheologic alterations have been extensively described in hemodialysis patients (HD), while little data on hemorheology exist about peritoneal dialysis patients (PD). Aim of our study is to characterize the hemorheological profile of 49 PD, and to compare these data with HD and healthy volunteers. PD showed an improvement of parameters related to macro-circulation (plasma viscosity, whole blood viscosity at 1-Hz, erythrocyte aggregation index and yield stress) when compared to HD, while microcirculatory function resulted severely impaired, as expressed by high values for whole blood viscosity 200-Hz shear rate and lower erythrocyte deformability (ED). In conclusion, we found hemorheologic alterations in PD, with substantial differences with respect to HD; in particular, PD showed profound dysfunction in microcirculatory flow with impaired ED. This alterations may act as a risk factor for accelerated atherosclerosis and precipitate cardiovascular events, and it may have a detrimental effect in the peritoneal microcirculation promoting endothelial activation with subsequent fibrosis, leading to peritoneal membrane malfunctioning.

Psychosocial well-being after kidney transplantation: A matched-pair case-control study

A number of outcome studies showed that kidney transplantation is associated with improvements in health-related quality of life relative to the pre-transplant period, but comparisons with the general population produced mixed results. This study aimed to compare 30 successful (>1 year) kidney transplantation recipients with 30 matched-pair healthy controls on psychosocial well-being. Independent of gender, age and time since transplantation, transplanted patients equalled healthy people in the intrapersonal domains but scored worse in the interpersonal domains of psychosocial well-being. Identifying aspects of life that remain impaired after kidney transplantation may assist the development of interventions targeted at improving patients’ adjustment.

Everolimus, cyclosporine, and thrombotic microangiopathy: clinical role and preventive tools in renal transplantation

INTRODUCTION

Thrombotic microangiopathy (TMA) is characterized by endothelial cell injury and formation of fibrin thrombi within capillary and arterioles. In renal allograft recipients, TMA mainly presents as hemolytic uremic syndrome. Its occurrence is rare, and diagnosis requires a high degree of suspicion. Drug toxicity, in particular from calcineurin inhibitors (CNIs) and mTOR inhibitors (mTORi), is the most common cause posttransplant and has recently been emphasized in the setting of lung transplantation.

OBJECTIVE

The goal of this study was to investigate the role of mTORi as an added risk factor in the development of TMA to propose strategies for modulation of immunosuppressive (IS) therapy.

PATIENTS AND METHODS

From a database of 496 renal graft recipients, we analyzed 350 renal graft biopsy specimens gathered at our center from 1998 to 2012. In patients undergoing combined therapy with mTORi and CNI, we compared drugs levels in TMA-affected and TMA-free groups, using mTORi and CNI TLC and the summation of [everolimus TLC+(cyclosporine C2/100)] (Σ) as a surrogate marker of combined exposition to 2 drugs. Receiver-operating characteristic analysis of association of EVL TLC+(C2/100) was performed for patients exposed to mTORi.

RESULTS

Histologic features of TMA were found in 36 patients (prevalence of 7.3%). The caseload was divided into 2 groups: not drug-related TMA (n=19) and drug-related TMA (n=17). Despite the prevalence of TMA in patients exposed to mTORi being greater (8 of 153; prevalence, 5.3%) compared with therapies without mTORi (9 of 324; prevalence, 2.8%), statistical difference was not reached. Patients treated with mTORi who developed de novo drug-related TMA had higher blood levels of IS drugs compared with those who did not develop TMA. Receiver-operating characteristic analysis found a significant threshold of 12.5 ng/mL (area under the curve, 0.803; P=.006).

CONCLUSIONS

Results confirm the pivotal role of IS drugs in the onset of de novo TMA. On the basis of literature, we could speculate a sequence of endothelial damage by CNI, on which everolimus fits hindering the repair of endothelial injury. Therefore, high blood levels of CNI and mTORi seem to predispose patients to posttransplant TMA. Combined monitoring of these 2 drugs might be used to prevent the complication. Σ [everolimus TLC + (cyclosporine C2/100)]>12.5 ng/mL should be avoided as a surrogate risk factor for adverse effects.

The Kidney Donor Profile Index (KDPI) of marginal donors allocated by standardized pretransplant donor biopsy assessment: distribution and association with graft outcomes

Pretransplant donor biopsy (PTDB)-based marginal donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the United States. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score<4 [median KDPI: 87; interquartile range (IQR): 78-94] and 62 with a score=4 [median KDPI: 87; IQR: 76-93]; 102 dual transplants [median KDPI: 93; IQR: 86-96]) and 248 single standard transplant controls (median KDPI: 36; IQR: 18-51). PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year estimated GFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9 and -18.8 mL/min, for dual transplants, single kidneys with PTDB score<4 and =4, respectively; p<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80-1.79; p=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded.

Protective effects of the melanocortin analog NDP-α-MSH in rats undergoing cardiac arrest

We previously reported that melanocortins afford cardioprotection in conditions of experimental myocardial ischemia/reperfusion, with involvement of the janus kinases (JAK), extracellular signal-regulated kinases (ERK) and signal transducers and activators of transcription (STAT) signalings. We investigated the influence of the melanocortin analog [Nle(4), D-Phe(7)]α-melanocyte-stimulating hormone (NDP-α-MSH) on short-term detrimental responses to cardiac arrest (CA) induced in rats by intravenous (i.v.) administration of potassium chloride, followed by cardiopulmonary resuscitation (CPR) plus epinephrine treatment. In CA/CPR rats i.v. treated with epinephrine (0.1 mg/kg) and returned to spontaneous circulation (48%) we recorded low values of mean arterial pressure (MAP) and heart rate (HR), alteration of hemogasanalysis parameters, left ventricle low expression of the cardioprotective transcription factors pJAK2 and pTyr-STAT3 (JAK-dependent), increased oxidative stress, up-regulation of the inflammatory mediators tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), and down-regulation of the anti-inflammatory cytokine IL-10, as assessed at 1h and 3h after CPR. On the other hand, i.v. treatment during CPR with epinephrine plus NDP-α-MSH (340 μg/kg) almost completely restored the basal conditions of MAP and HR, reversed metabolic acidosis, induced left ventricle up-regulation of pJAK2, pTyr-STAT3 and IL-10, attenuated oxidative stress, down-regulated TNF-α and IL-6 levels, and improved survival rate by 81%. CA/CPR plus epinephrine alone or in combination with NDP-α-MSH did not affect left ventricle pSer-STAT3 (ERK1/2-dependent) and pERK1/2 levels. These results indicate that melanocortins improve return to spontaneous circulation, reverse metabolic acidosis, and inhibit heart oxidative stress and inflammatory cascade triggered by CA/CPR, likely via activation of the JAK/STAT signaling pathway.

Retroperitoneoscopic single site renal biopsy surgery: right indications for the right technique

Bacground

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the morbidity and scarring associated with laparoscopic surgery. In patients in whom there are indications to perform a laparoscopic renal biopsy, LESS surgery is a valid alternative to mini invasive surgery and is becoming more common. We report our experience on 14 renal biopsy procedures performed in a retroperitoneal LESS.

Methods

LESS renal biopsy was performed in 14 patients 18 to 80 years old (mean age 58.3 years) during a 36 month period. All procedures were performed by a single operator. The patient was in a standard flank position. The procedure was performed using a 2.5 cm, single incision via a retroperitoneal access at the Petit’s triangle. A 5 mm biopsy forceps was used to collect the specimen under direct vision, and haemostasis was obtained with an Argon beam probe and the application of oxidized regenerated cellulose gauze.

Results

Biopsy was performed successfully in all cases. Mean operative time was 52.64 min, blood loss was minimal, and the hospital stay ranged from 12 to 24 hours. None of the patients required narcotics or additional analgesia in the postoperative period. No postoperative complications occurred.

Conclusions

The LESS technique is safe, reliable (100% success), easy to learn, and offers subjective cosmetic benefits to the patient. Minimal hospitalization requirement following retroperitoneal LESS biopsy is an additional timely advantage over laparoscopic renal biopsy. We think that with the right indications (marked obesity, failure of previous percutaneous biopsy attempts, a solitary kidney and coagulopathy) LESS renal biopsy is a good alternative to laparoscopy. Our next step will be a randomized prospective study of LESS compared with laparoscopy for renal biopsy to support our findings.

Identification and characterization of a new autoimmune protein in membranous nephropathy by immunoscreening of a renal cDNA library

Membranous Nephropathy (MN) represents a large amount of Nephrotic Syndromes in the adult population and its definitive diagnosis is currently carried out through biopsy. An autoimmune condition has been demonstrated in idiopathic MN (iMN) in which some kidney structures are targeted by patient autoantibodies. Some candidate antigens have been described and other likely involved target proteins responsible for the disease are not known yet. In this work our aim is to identify these proteins by screening a lambda-phage library with patients' sera. We enrolled four groups of patients: two MN groups of 12 full iMN patients; one control group of 15 patients suffering from other renal diseases; one control group of 15 healthy individuals. A commercial cDNA phagemide library was screened using the above described sera, in order to detect positive signals due to antigen-antibody bond. We detected one phagemide clone expressing a protein which was shown to be targeted by the antibodies of the iMN sera only. Control sera were negative. The sequence analysis of cDNA matched the Synaptonemal Complex protein 65 (SC65) coding sequence. Further proteomic analyses were carried out to validate our results. We provide evidence of an involvement of SC65 protein as an autoimmune target in iMN. Considering the invasiveness and the resulting risk coming from renal biopsy, our ongoing aim is to set a procedure able to diagnose affected patients through a little- or non-invasive method such as blood sampling rather than biopsy.

Combined liver-kidney transplantation in patients infected with human immunodeficiency virus

Although human immunodeficiency virus (HIV) infection has been a major global health problem for almost 3 decades, with the introduction of highly active antiretroviral therapy in 1996 and effective prophylaxis and management of opportunistic infections, mortality from acquired immunodeficiency syndrome has decreased markedly. In developed countries, this condition is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney, and heart disease are steadily increasing in individuals with HIV. Because the definitive treatment for end-stage organ failure is transplantation, the demand for it has increased among HIV-infected patients. For these reasons, many transplant centers have eliminated HIV infection as a contraindication to transplantation, as a result of better patient management and demand.

[Post-transplant recurrence of glomerulonephritis: a complex clinical case]

Lupus nephritis (LN) seldom recurs in a grafted kidney. By contrast, primary membranoproliferative glomerulonephritis (MPGN), which has been included, along with hemolytic uremic syndrome and age-related maculopathy, among the complement dysregulation diseases, has a high recurrence rate and is considered a contraindication to living-donor kidney transplant because of the poor prognosis. We report the case of a young girl with LN-related chronic renal failure who underwent a living donor transplant from her mother. After four months she had a recurrence that did not match the criteria for LN. Graft biopsies and revision of the clinical course pointed to type II MPGN on the basis of a lack of ARA criteria, persistent isolated low C3 levels, and response to plasma therapy. If confirmed by genetic analysis, the patient might benefit from treatment with the monoclonal antibody against the C5-C9 complex, eculizumab.

Chronic kidney disease certification process manual by the Italian Society of Nephrology (SIN): part II: programme management and clinical information management

This is the second part of a document describing a voluntary certification process based on Joint Commission International (JCI) criteria developed by the Italian Society of Nephrology (SIN) and JCI representatives. In the first part we discussed standards for clinical care delivery and performance measurements related to chronic kidney disease care. Herein (Part II), we complete the description of Performace measurements and CKD care by describing issues related the management and clinical information management.

Chronic kidney disease certification process manual by the Italian Society of Nephrology (SIN): Part I: clinical care delivery and performance measurements and improvement

Chronic kidney diseases (CKD) has now emerged as a public health priority, and there is an increasing demand by patients and health care organisations that the quality of care delivered by renal units to CKD patients be systematically monitored and evaluated. The Italian Society of Nephrology (SIN) has started an initiative aimed at promoting a quality certification process specifically focused on CKD. To this end, SIN started a collaboration with an independent Italian company which is a partner of Joint Commission International (JCI), a nonprofit international organisation dedicated to the promotion of quality improvement and safety of health services. As a result of this collaboration, a document describing a voluntary certification process developed based on JCI criteria was produced by SIN. This document comprises 2 parts. Herein (Part I) we deal with standards for clinical care delivery and performance measurements related to CKD care. Programme management and clinical information management will be presented in a separate manuscript (Part II).

Glomerular filtration rates in HIV-infected patients treated with and without tenofovir: a prospective, observational study

OBJECTIVES

The aim of our study was to assess the impact of plasma HIV-1 RNA level [viral load (VL)] variation and tenofovir exposure on kidney functions by analysing changes in calculated glomerular filtration rates (GFRs) over a 48 week period in patients with mild renal impairment.

PATIENTS AND METHODS

A prospective observational study that included data from all consecutive HIV-infected patients who attended a metabolic clinic was conducted. Included were adult, antiretroviral (ARV)-experienced, tenofovir-naive patients, whose kidney functions were evaluated by calculated GFR using the simplified Modification of Diet in Renal Disease study equation (MDRD). Tenofovir-exposed patients were patients who initiated tenofovir therapy at baseline and tenofovir-unexposed patients were patients whose ARV therapy did not include tenofovir. Participants were stratified into three sub-groups according to the plasma HIV-1 RNA (VL) changes observed: sub-groups 1, 2 and 3 were patients with stable VL < or =50 copies/mL, >0.5 log(10) VL increases and >0.5 VL log(10) decreases, respectively.

RESULTS

Ninety-nine patients were enrolled and included in the analysis. Within the tenofovir-unexposed group, GFRs remained stable (ANOVA, P = 0.94) over the follow-up period. Within the tenofovir-exposed group, mean GFR changes varied significantly by sub-group (ANOVA, P < 0.01). In particular, GFR changes in sub-group 3 (+8.4 +/- 12.4 mL/min) were different from those seen in sub-group 1 (-1.0 +/- 8.8 mL/min) (P < 0.05) and sub-group 2 (-4.6 +/- 8.8 mL/min) (P < 0.01).

CONCLUSIONS

Observed improvements in GFR that occurred as a consequence of highly active ARV therapy-induced viral suppression may have more than offset any potential negative effects of tenofovir on renal function.

Psychological factors associated with medication adherence following renal transplantation

BACKGROUND

A relationship exists between non-adherence and clinical outcomes in health care, including renal transplantation. The aim of this study was to identify the psychological variables associated with non-adherence to medication after renal transplantation.

METHODS

This cross-sectional study involved 34 patients, 38% male, with a mean age of 49 yr (range 26-70) and a mean of six yr post-transplantation. Adherence to medication was measured by two items: (i) the frequency of not taking medications and (ii) the frequency of not taking medications exactly as prescribed. The psychological variables were: dispositional coping style (COPE) and five items measuring barriers and perceived characteristics of the medication regimen. Descriptive and multivariate analyses were utilized to examine the data.

RESULTS

Twenty-four per cent of patients reported less than perfect adherence. Individuals who were younger, who perceived less autonomy in the management of treatment and who were characterized by an active coping style were less likely to adhere to medication. Individuals who perceived less autonomy and a higher level of interference of treatment with their life patterns were less likely to take medication exactly as prescribed.

CONCLUSIONS

The finding of this study suggests that adherence to medications after renal transplant is associated with psychological variables, such as coping style and perceived autonomy in the management of treatment. Understanding of the patient's perspective may help to develop effective interventions to increase the levels of adherence to medications that may result in better clinical outcomes.

[Nurse's coworking to electronic medical record]

Nephrologists need to register and look at a great number of clinical data. The use of electronic medical records may improve efficiency and reduce errors. Aim of our work is to report the experience of Villa Scassi Hospital in Genoa, where a "patient file" has been performed to improve nephrology practice management. The file contains all clinical records, laboratory and radiology data, therapy, dialysis clinics, in addition to reports of out-patients department. This system allowed a better efficiency in diagnosis and treatment of the patient. Moreover experience of nurses in employing electronic medical records is reported. A reduced number of errors was found in therapy administering, because of a only one data source for physicians and nurses.

["Terzo fuoco", lead poisoning and chronic renal failure]

BACKGROUND

In ceramics, "Terzo fuoco" (Third fire) means a third firing of clay to fix colors on tiles or pottery. The low firing temperatures (800-900 degrees C) and the use of a spray gun are risk factors for lead poisoning. Because of their small size, handicraft companies often fail to implement the preventive measures that are utilized efficiently in large tile factories. We report a case of chronic lead poisoning with special emphasis on diagnostic tools and treatment goals.

CASE REPORT

A 38-year-old woman was hospitalized in 2005 because of grade 3 chronic renal failure (serum creatinine 1.69 mg%, Cockroft-Gault glomerular filtration rate [GFR] 45 mL/min), hypertension and elevated serum uric acid (13.4 mg%) without gout. She had been previously hospitalized elsewhere and diagnosed as suffering from hypertensive nephropathy. Her occupational history included acute lead poisoning 12 years before, which was treated with a short leave from work. She subsequently continued her job, using a spray gun for decorative drawing in a small tile company until 2004. Because of a low GFR she underwent a 3-day chelation test with 750 mg CaNaEDTA i.v., and excreted 1056 microg Pb (n.v < 600 microg) -- (PbU/EDTA ratio 1.41; n.v < 0.6). A renal biopsy showed chronic interstitial nephropathy with severe arteriolosclerosis. The patient was treated with 5 courses of EDTA, resulting in a final Pb excretion of 517 microg/72 h (PbU/EDTA 0.69). Her serum creatinine fell to 1.32 mg% (CFR 58 mL/min). A further course of chelation therapy is planned.

DISCUSSION AND CONCLUSIONS

The EDTA chelation test allows to determine the lead body burden (PbBB) and to titrate subsequent chelation therapy. Recent papers have shown that PbBB is a major factor in the progression of chronic renal failure besides pressure control, and have indicated a PbBB safety level of less than 100 microg/test (PbU/EDTA < 0.1). In order to prevent the development of chronic renal failure, it is important that not only occupational but also environmental lead exposure be identified and adequately treated.

Quality of water, dialysate and infusate

Great improvements in water treatment technology and the spread of ultrafiltration for cold sterilization have been the basic support for the development and diffusion of on-line dialysis treatments. Some 20 years ago, nephrologists recognized that the official standards for dialysis fluids were insufficient with respect to these new treatment modalities, and ultrapure water (bacteria <0.1 CFU/ml; endotoxin <0.03 EU/ml) was proposed as a reference. Today, ultrapure water is included in most guidelines and recommended standards, but there remains a need for harmonization between standards. To achieve and ensure these levels of purity, technology must be supported by commitment of resources to an active quality assurance programme with adequate maintenance, monitoring, cleaning, sanitizing and problem analysis procedures.

Distortion product otoacoustic emissions in otosclerosis: intraoperative findings

The aim of the study was to investigate changes in middle ear dynamic characteristics caused by both otosclerosis and stapes surgery (platinotomy, prosthesis positioning, ossicular chain maneuver) and to evaluate distortion product otoacoustic emissions (DPOAEs) before and following surgery. The study included 15 patients (12 women, 3 men; mean age 51 years; range 32-69 years) with advanced otosclerosis. All the patients were evaluated with the use of pure-tone audiograms (preoperatively, 5 and 30 days after surgery), stapedial reflexes (preoperatively), and DPOAE recordings (preoperatively, at the end of surgery, and 5 and 30 days after surgery). Changes in the hearing thresholds and in the DPOAE amplitudes were compared. Preoperative tests showed conductive hearing loss, with a mean air-bone gap of 36.6 dB HL ranging from 0.25 to 1 kHz, and no stapedial reflexes were detected. DPOAEs were not measurable preoperatively, and they were detected only in 2 patients at the end of surgery, with low amplitudes in a narrow frequency range. No significant changes occurred in DPOAEs 5 days postoperatively. A month after surgery, improvement in conductive hearing loss was observed; the mean air-bone gap from 0.25 to 1 kHz was 12.9 dB HL, whereas the higher frequencies were still affected by the disease. DPOAEs increased in amplitude in 4 patients, but this was not significant. It remains unclear why DPOAEs are not detected despite a subjective hearing improvement and a sufficiently closed air-bone gap at least in middle and low frequencies. The results of our study show that DPOAEs cannot replace behavioral threshold tests; they may only be included in a battery of tests for a complete clinical follow-up for efficiency monitoring after stapes surgery.

Biofilm on artificial surfaces

Biofilms are microbial communities quite different from planktonic cells and most of common microbiological concepts had to be updated in recent years. The peculiar capacity to resist to disinfectants and antibiotics results in biofilms being a public health problem mainly when modern medical devices are used. All artificial surfaces used in medicine may be prone to biofilm attachment and could therefore represent a cause of acute or chronic infectious diseases. Uremic patients are at higher risk from biofilms as not only traditional causes, such as indwelling catheters, but also hemodialysis apparatuses contribute to bacterial exposure. Chemical or physical disinfections have been demonstrated partially active on sessile microorganisms and biofilm avoidance remains the goal to assure an adequate quality of dialytic treatment.

[Census 2004 of the Italian Renal and Dialysis Units. Emilia-Romagna, Toscana]

The 2004 SIN census of the Italian nephrology and dialysis centres showed many interesting data about the epidemiology and the organization in the Regions of Emilia-Romagna (ER) and Tuscany (T). A) Epidemiology: incidence of dialysis patients 169 pmp (patients per million population) in ER, 147 ppm in T; prevalence of dialysis patients 639 pmp and 665 pmp, respectively; prevalence of transplanted patients 325 ppm in ER and 233 pmp in T; gross mortality of dialysis patients 16.3% and 13.4%, respectively; B) Type of vascular access in prevalently dialysis patients: arteriovenous fistula 83% and 78%; central venous catheter 13% and 12%; vascular graft 5% and 9%. C) Structural resources: nephrology beds 44 mp (per million population) and 50 mp; dialysis places 157 and 146 mp. D) Personnel resources : renal physicians 29 and 41 mp; renal nurses 171 and 202 mp ; each renal physician cares for 22 and 16 dialysis patients, and each renal nurse takes care of 3.7 and 3.3 dialysis patients. E) Activity: hospital admissions 1572, 1769 pmp; renal biopsies 115 and 166 pmp.

[Update of the Italian Society of Nephrology Project No. 1 of the 2004-2006 SIN programme]

In the last few years the Italian Society of Nephrology has addressed many technical-scientific and management aspects to better patient satisfaction. Project No. 1 of the 2004-2006 programme on 'Quality and Accreditation of National Renal Units' focuses on four essential points. The first is the questionnaire mailed to all the Presidents and Regional Delegates on the relationship between Nephrology units, Local Government Health-System and the Regional Healthcare Agency. The results evidence that the 'political' decision-making power of nephrologists decreases in the absence of a national strategy. The second point, in collaboration with the National Census Group, includes the quality analysis and the standardization of resources (human and structural) and management of the Renal Units. The third point is based on 'Educational Courses for Quality and Accreditation' held in Rome (3-5 October 2005: L'Accreditamento all'Eccellenza dell'Unita' Operativa di Nefrologia, Dialisi e Trapianto; 17-19 October 2005: Il Manuale di Accreditamento della Specialità di Nefrologia). The courses aim at training members responsible for each region to hold courses in their specific region to create a network including each single Renal Unit to create an acceptable homogenous language on the models of analysis and on the correct use of 'The Guide for Excellence Accreditation'. The fourth point concerns both the on-line Guide for Excellence Accreditation and 'Peer Review Accreditation' and the NEQUASY (Nephrology Quality System) project. The manual must be 'user friendly' allowing each Centre to self-evaluate using national and regional standards.

Water treatment and monitor disinfection

Water treatment system and dialysis monitors are susceptible to microbial contaminations and periodical disinfection procedures are mandatory to obtain results requested from international standards and guidelines. Several chemical germicides or some physical treatments are on the market validated by device manufacturer according to medical device directives. With time, interfering substances from dialysis device or water are able to modify disinfection efficiency. Simulating-use testing is not a common procedure to validate disinfectants and recent data document as biofilm represents the most important cause of disinfection inefficacy. Some international standards include tests in the presence of various interfering substances but their use is not widespread. When using a disinfectant, residue toxicity, material compatibility and potential risks for the staff also have to be considered. A quality assurance program has to be implemented to obtain adequate performances and to improve results on patients.

Characterization of drug-resistance mutations in HIV-1 isolates from non-HAART and HAART treated patients in Burkina Faso

Non-B HIV subtypes have been estimated to account for 88% of HIV infections in the world. These subtypes are particularly relevant in view of the availability of antiretroviral (ARV) drugs, since subtype-specific mutations are associated with drug-resistance in developing countries. Therefore, the pol gene sequences in HIV-1 isolates were examined from the three distinct groups of 39 infected patients from Ouagadougou in Burkina Faso: 17 patients who had not received any antiretroviral therapy (ART); 16 patients received ART, and 6 HIV-infected children, from infected mothers, received a single Nevirapine dose prophylaxis during birth. HIV-1 pol sequencing was successful for 29 samples. As expected, all patients presented the common (non-B subtype) M36I polymorphism and 26/29 (90%) the K20I mutation. Phylogenetic studies showed high predominance of recombinant HIV-1 strains: CRF06_cpx 16/29 (55.17%), CRF02_AG 9/29 (31.03%), A1 2/29 (6.89%), G 1/29 (3.44%), and CRF09_cpx 1/29 (3.44%). Two twins showed, 6 months after birth, a NNRTI-mutation (Y181C/Y). During the same period, the twin mother presented a different NNRTI-mutation (V106I), thus suggesting that the different blood drug concentration may determine a different drug-resistance pathway. Among 17 non-highly active antiretroviral therapy (HAART) patients, 3/17 (17.64%) presented virus with reverse transcriptase (RT) mutations [V118I: 1/17 patients (5.88%), V179E: 2/17 patients (11.76%)]. 10/17 (58.82%) presented virus with minor protease (PR) mutations [L63P: 5/17 patients (29.41%), V77I: 3/17 patients (17.64%), L10I: 2/17 patients (11.76%)]. 4/17 patients did not show any PR and RT mutations (23.52%). Among six HAART-treated patients, 6/6 and 3/6 had M36I and L63LP protease minor subtypes, respectively; and only two (33.33%) presented virus with K103N mutation. The low prevalence of drug-resistant associated mutations in Burkina Faso is encouraging. However, further studies with a larger cohort with a high non-B subtype prevalence are necessary to optimize ART in developing countries.

[The Dialysis Outcomes and Practice Patterns Study (DOPPS): results of the Italian cohort]

BACKGROUND

The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective, longitudinal, observational study examining the relationship between dialysis unit practices and outcomes for hemodialysis (HD) patients in seven developed countries France, Germany, Italy, Spain, United Kingdom, Japan and the United States. Results of the DOPPS in Italy are the subject of this report.

METHODS

A national representative sample of 20 dialysis units (21 in Germany) was randomly selected in each of the European DOPPS countries (Euro-DOPPS). In these units, the HD in-center patients were included on a facility census, and their survival rates continuously monitored. A representative sample of incident (269 in Italy, 1553 in the Euro-DOPPS) and prevalent (600 in Italy, 3038 in the Euro-DOPPS) patients was randomly selected from the census for more detailed longitudinal investigation with regard to medical history, laboratory values and hospital admission.

RESULTS

Comparing the Italian and Euro-DOPPS cohorts we found comparable mean age for prevalent patients (61.4 vs. 59.5 yrs), but incident patients were older in Italy. Italian prevalent patients had less cardiovascular disease, more satisfactory nutritional status and more frequent use of native vascular access. These data were associated with a comparable mortality (15.7 vs. 16.3 deaths/100 patient yrs), but morbidity was lower in Italy. Kt/V levels were comparable in the two cohorts (1.32 vs. 1.37), but 35% of Italian patients showed a Kt/V below the recommended target. Moreover, hemoglobin levels were below 11 g/dL in 60% of Italian patients.

CONCLUSIONS

The DOPPS results bring to light several positive aspects and the opportunity for further possible improvements for Italian patients, but at the same time highlight some critical points that could represent a risk for dialysis quality.

Water treatment for hemodialysis: a 2005 update

Water for dialysis represents an additive risk factors to the chronic inflammatory state documented in patients on ESRD. The possibility of sustaining proinflammatory cytokines through microbial derived products, coming from dialysate or infused solutions, is enhanced by biofilm presence on piping and on water treatment system or monitor components. Spread use of reverse osmosis, loop distribution system and pre-treatment components tailored to local raw water characteristics have greatly contributed to a general improvement in final water quality. Notwithstanding these contributions literature still reports fatal accidents or significant percentage of dialysis units not complying to the water quality standards. Technological improvement lowers chemical contamination but microbial quality relays more on quality assurance programs than on technology. Optimal water quality represents part of the anti-inflammatory strategies we need to assure to our dialysis patients to improve outcome.

[SIN survey on quality control of dialysis water in Italy]

BACKGROUND

The importance of high quality water for dialysis is well established. This study aimed to obtain a picture of the Italian situation to develop national guidelines.

METHODS

Questionnaire analysis was used to assess water quality control protocols and types of chemical and microbiological parameters monitored. Regions with responses from at least half the units were considered for the study.

RESULTS

Eighteen out of 20 regions fulfilled the inclusion criteria; 297/469 dialysis units answered the questionnaire (5208 dialysis beds, 18213 patients). Eighty-one percent of Italian units follow a regular water quality control program. The reverse osmosis outlet is the sampling point used most for assessing chemical and microbiological parameters. The most common frequency in monitoring is < or =6 months. Fifteen chemical items, suggested by the Italian Farmacopea Ufficiale (FU), are periodically controlled by at least half the units. Aluminum is measured in about 70% of units, chloramines and volatile halogenated hydrocarbons, respectively, in 42 and 30% of units. According to the FU, bacterial counts at 22 degrees C (84%) and endotoxin determinations (60%) are the most common microbiological analyzes.

CONCLUSIONS

The survey demonstrated protocol differences among the units, confirming the need for Italian guidelines to ameliorate and standardize dialysis water monitoring. More than half the units are following the FU, but we cannot rule out less strict monitoring only in non-participating units.

[Guidelines on water and solutions for dialysis. Italian Society of Nephrology]

The National Society of Nephrology has promoted the development of specific Italian Guidelines for dialysis fluids. Two previous national inquiries showed a wide variety in the type and frequency of both microbiological and chemical controls concerning dialysis water, reinforcing the need for specific standards and recommendations. An optimal water treatment system should include tap water pre-treatment and a double reverse osmosis process. Every component of the system, including the delivery of the treated water to the dialysis machines, should prevent microbiological contamination of the fluid. Regular chemical and microbiological tests and regular disinfection of the system are necessary. 1. Chemical quality (Table: see text). Treated tap water used to prepare dialysis fluid should be within European Pharmacopoeia limits at the water treatment system inlet and at the reverse osmosis outlet. In addition dialysate, concentrate and infusion fluids must comply with specific Pharmacopoeia limits. The physician in charge of the dialysis unit is advised to institute a multidisciplinary team to evaluate the requirement for added chemical controls in the presence of local hazards. 2. Microbiological quality (Table: see text). High microbiological purity of dialysis fluid--regularly verified--is a fundamental prerequisite for dialysis quality and every dialysis unit should aim as a matter of course to obtain "ultra-pure" dialysate (microbial count <0.1 UFC/mL, endotoxins <0.03 U/mL). On-line dialysate ultrafiltration and regular disinfection of dialysis machines greatly enhance microbiological purity. On-line dialysate reinfusion requires specific devices used according to corresponding instructions and to more frequent microbiological tests. Dialysis fluids for home dialysis should comply with the same chemical and bacteriological quality. The appendix reports the water treatment system's technical characteristics, sampling and analytical methods, monitoring time-tables, as well as the origin and effects of the main toxic substances. Suggestions and questions concerning these guidelines are welcome to nefrologia@sin-italy.org.

[Italian Registry of Dialysis and Transplantation: 1996-2001 experience]

The Italian Registry of Dialysis and Transplantation (RIDT) was born in 1996 under the aegis of the Italian Society of Nephrology, and it is organized as a federation of regional registries. This study aimed to completely revise the epidemiological data collected during the first 5 yrs (1996-2001) of RIDT activity to evaluate the trends of the main epidemiological features. During this period, regional registries were not always able to assure complete and exhaustive information according to RIDT requirements, owing to different levels of organization and functioning. To avoid any possible error in data analysis, information inadequately assessed was refused. The incidence of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT) in Italy has increased from 114 pmp in 1996 to 139 pmp in 2001, that means an increase of 3.5%/yr, corresponding to 5718 patients during 1996 and 8000 patients during 2001. Primary renal diseases (according to the EDTA) in incident ESRD patients are vascular and diabetic nephropathy. Main dialysis modality in incident patients was hemodialysis (HD) (85%), while peritoneal dialysis (PD) was only 15%; pre-emptive transplantation was a very unusual modality. The prevalence of ESRD patients at 31 December was 693 pmp in 1996 and 827 pmp in 2001; among dialysis patients, the corresponding rates were 575 pmp and 657 pmp, respectively. Consequently, the number of dialyzed patients increased, respectively, from 28892 to 37919. The prevalent dialysis modality was bicarbonate dialysis in 74% of cases, followed by hemodiafiltration (HDF) in 15%, continuous ambulatory peritoneal dialysis (CAPD) in 7% and APD in 3%. The gross mortality rate in dialyzed patients was stable during this period, at approximately 14%, the main causes of death being cardiovascular diseases and cachexia.

Effects of biofilm formation on haemodialysis monitor disinfection

BACKGROUND

Biofilms are composed of communities of micro-organisms adhering to essentially any surface. We evaluated whether biofilm formation in the hydraulic circuit of a purposely contaminated haemodialysis monitor would modify the efficacy of different disinfection modalities against bacteria and endotoxin concentrations.

METHODS

A water-borne Pseudomonas aeruginosa (109) suspension was recirculated for 1 h and was left standing for 72 h (stationary phase) in the hydraulic circuit of the monitor. The monitor was then washed and disinfected by different physical (heat, 85 degrees C) or chemical (hypochlorite or peracetic acid) disinfection modalities (protocol A). In protocol B, the bacterial suspension was also recirculated for 1 h, but the monitor was then immediately washed and disinfected by different chemical disinfection modalities (hypochlorite or peracetic acid).

RESULTS

Biofilm formation was revealed by scanning and confocal laser electron microscopy after the stationary phase (protocol A), but was absent when the monitor was immediately washed and disinfected (protocol B). In the presence of biofilm (protocol A), heat in association with citric acid was the most effective modality for reducing both colony forming units and endotoxin concentrations, whereas heat by itself was the least effective method of disinfection. Dwelling (60 h) with diluted peracetic acid completely prevented the formation of biofilm. In the absence of biofilm (protocol B), chemical disinfection proved to be effective against both colony forming units and endotoxin concentrations.

CONCLUSIONS

We found that biofilm formation may markedly reduce the efficacy of presently available disinfection modalities. Therefore, different disinfection modalities and the combined action of descaling (by citric acid) and disinfection (physical/chemical agents) should be used periodically in haemodialysis monitors. In addition, dwelling with diluted peracetic acid should be adopted whenever monitors are not in use.