The Effect of Dialysate Temperature on Dialysis Adequacy and Hemodynamic Stability: An Experimental Study with Crossover Design

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Gerry George Mathew

DOI: 10.69097/41-04-2024-12

Gerry George Mathew1, Suganya Muthukarupiah2, Muthamizh Muniappan3, Judhajit Maiti4, Varadharajan Jayaprakash5

1 Associate Professor, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu, Tamil Nadu, India-603203
2 Senior resident, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu, Tamil Nadu, India-603203
3 Lecturer, Renal dialysis Technology. Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu, Tamil Nadu, India-603203
4 Senior resident, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu, Tamil Nadu, India-603203
5 Professor and Head, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Chengalpattu, Tamil Nadu, India-603203

Corresponding author:
Gerry George Mathew
E-mail: gerrygeorge007@gmail.com
Mobile no: +91-8291077361

 

Abstract

Cool dialysate has variable impact on hemodynamic stability and dialysis adequacy.  Hemodynamic stability and dialysis adequacy are crucial indicators for better life expectancy and cardiovascular mortality. This research aims to evaluate the impact of cool dialysate temperature (35.5°C) compared to standard dialysate temperature (37°C) on blood pressures, pulse rate, and dialysis adequacy (Urea reduction ratio and online Kt/V) in a cross over design.
Material and Methods. Consenting ESRD patients on maintenance haemodialysis (HD) with minimum 3 months dialysis vintage and functioning permanent vascular access are included for the study. Each participant had two sessions of HD at 37°C followed by two sessions at 35.5° C on a Fresenius 4008S HD machine. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and Pulse rate are measured pre-HD, every hourly and post dialysis. Pre-HD Blood urea nitrogen (BUN) and post-HD BUN are measured, and Urea reduction rate was calculated for each HD session. Kt/V was calculated by ionic conductance by HD machine for each session.
Results. 25 patients (5 females and 20 males) were enrolled. The mean age was 54 ± 9.58 years. Dialysis vintage was 21.48 ± 6.9 months for study participants 10 patients (40%) were diabetic nephropathy, 9 patients (36%) were presumed chronic glomerulonephritis, 2 patients (8%) were lupus nephritis and 4 patients (16%) were chronic interstitial nephritis. There was statistically no difference between pre-HD BUN (p = 0.330), post-HD BUN (p = 0.776), URR (p = 0.718) and Kt/V (p = 0.534) among the dialysis sessions done at 37°C and 35.5°C.
SBP variability in the low temperature (35.5°C) group at 4th hour and post dialysis assumed statistical significance with p = 0.05 and p = 0.025 respectively. DBP variability in the low temperature (35.5°C) group at 3rd hour, 4th hour and post-dialysis demonstrated statistical significance with p = 0.027, p = 0.36 and p = 0.016 respectively. Pulse rate variability was more in the low temperature (35.5°C) group at 3rd hour and 4th hour which showed statistical significance with p = 0.037 and p = 0.05 respectively.
Conclusion. Cool dialysate is non inferior to standard dialysate temperature in terms of dialysis adequacy and is associated with less variability in diastolic blood pressure, systolic blood pressure and more pulse rate variability thereby contributing to better hemodynamic stability.

Keywords: Cool dialysate, Dialysis adequacy, Hemodynamic stability, Pulse rate variability

Introduction

Hemodynamic stability and dialysis adequacy in hemodialysis translates to better quality of life and greater life expectancy [1]. One of the most adopted practices to enhance hemodynamic stability and prevent intradialytic hypotension is the use of cool dialysate [2]. Cardiovascular stability is improved due to increased peripheral resistance and tonicity of blood vessels along with secretion of catecholamine in the clinical context of cool dialysate [3]. Cool dialysate has not become popular due to patient perception of chills and shiver during haemodialysis and its theoretical risk of inferior dialysis adequacy due to entrapment of blood in peripheral blood vessels [4].

Hemodynamic stability is a well-established impact of cool dialysate; however, its influence on the clearance of uremic toxins is still debatable. Intercompartmental resistance is still a realistic concern in cool dialysate which may deter clearance and contribute to dialysis inadequacy [5]. Previous studies [6] have analysed the hemodynamic variability associated with a cool dialysate, but only few studies have conjointly analysed hemodynamics and dialysis adequacy in the same clinical setting. Our study aimed at evaluating the impact of cool dialysis (35.5°C) compared to standard dialysate temperature (37 °C) on blood pressures, pulse rate and dialysis adequacy (Urea reduction ratio (URR) and online Kt/V) in a crossover design study. 

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Renal Functional Reserve in Naïve HIV Patients

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Carlos G. Musso

DOI: 10.69097/41-04-2024-11

Carlos G. Musso1,2, Rossina Juarez3, Belloso W4, Henry Gonzalez-Torres2, Mercedes Capotondo4, Terrasa Sergio1, Fabrizio Cristiano5,6, Gustavo Aroca Martinez 2,7

1 Research Department, Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
2 Facultad de Ciencias de la Salud. Universidad Simon Bolivar. Barranquilla, Colombia
3 Climedica Hospital. Buenos Aires, Argentina
4 Internal Medicine Department, Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
5 UOSD Nefrologia Dialisi. Ospedale di Ortona. Contrada Santa Liberata. Asl 2 Lanciano Chieti. Italia
6 Department of Neuroscience, Imaging and Clinical Scienze, G. d´Annunzio. University of Chieti-Pescara. 66100 Chieti, Italia
7 Nephrology Division. Clínica de la Costa. Barranquilla, Colombia

Corresponding author:
Carlos Guido Musso
Research Department, Hospital Italiano de Buenos Aires. Buenos Aires, Argentina
Telephone: 005411 49590200
Gascón 450, Ciudad Autónoma de Buenos Aires, Argentina
E-mail: carlos.musso@hospitalitaliano.org.ar

 

Abstract

Introduction. Renal functional reserve (RFR) is the kidney capability of increasing its basal glomerular filtration rate (GFR) at least 20% after an adequate stimulus. Renal disorders have been reported in seropositive HIV patients, particularly the decrease in glomerular filtration rate (eGFR), nephrotic syndrome, and proximal tubular deficiency associated with the disease itself or the use of some anti-retroviral treatments. Thus, it was decided to carry out a prospective study in order to evaluate if RFR test was preserved in naive HIV patients.
Material and Method. GFR was measured by using cimetidine-aided creatinine clearance (CACC), and RFR as described Hellerstein et al. in seropositive naive HIV patients and healthy volunteers.
Results. RFR was evaluated in 12 naïve HIV patients who showed positive RFR (24.8±2%), but significantly lower compared to RFR in 9 control individuals (90.3 ± 5%).
Conclusion. In this study was found that renal functional reserve was positive in naïve HIV patients, but significantly lower compared to renal functional reserve achieved by seronegative healthy individuals.

Keywords: renal reserve, HIV, renal physiology

Abbreviations

Renal Functional Reserve (RFR)
Glomerular Filtration Rate (GFR)
Human Immunodeficiency Virus (HIV)
Tenofovir Disoproxil-Fumarate (TDF)
Thick Ascending Limb of Henle’s Loop (TALH)
Tubular-Glomerular Feedback (TGF)
Cimetidine-Aided Creatinine Clearance (CACC)

 

Introduction                                                                                    

Renal functional reserve (RFR) is the renal capability of increasing its basal glomerular filtration rate (GFR) at least 20% after an adequate stimulus such as amino-acid infusion or oral protein overload. A positive renal reserve response requires the presence of both adequate glomerular and renal tubular function [1]. In order to evaluate GFR, one of the most simple and reliable method seems to be the cimetidine-aided creatinine clearance (CACC), particularly that which uses oral cimetidine supply. Since cimetidine inhibits creatinine secretion in the proximal tubules, the ratio of the CACC and GFR is about 1.1 [2–4]. 

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Clinical Thermography for the Management of Hemodialysis Vascular Access

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Giuseppe Gatta

DOI: 10.69097/41-04-2024-10

Giuseppe Gatta1, Antonio Scarlatella1, Francesco Aucella1, Maria Nardella1, David Perpetuini2, Michele Tritto3, Daniela Cardone2, Carlo Lomonte4, Arcangelo Merla2, Filippo Aucella1

1 U.O.C. Nefrologia e Dialisi, Fondazione “Casa Sollievo della Sofferenza” IRCCS, San Giovanni Rotondo (FG)
2 Dipartimento di Ingegneria e Geologia, Università G D’Annunzio di Chieti-Pescara
3 Next2u s.r.l. Pescara
4 U.O.C. Nefrologia e Dialisi, Ospedale “Miulli”, Acquaviva delle Fonti (BA)

Corresponding author:
Giuseppe Gatta
UOC Nefrologia e Dialisi IRCCS “Casa Sollievo della Sofferenza”,
Viale Cappuccini 1
71013  San Giovanni Rotondo, ITALIA
Tel.0882/410477
E-mail: g.gatta@operapadrepio.it

 

Abstract

The arteriovenous fistula (AVF) represents the favorite vascular access in individuals with chronic kidney disease (CKD). Because AVF is a guarantee of survival for these patients, proper surgical packing and a timely follow-up program is crucial.
Although a good objective examination of the limb site of FAV provides useful information both in planning the fistula surgery and in its surveillance and monitoring, it is now well established that the advent of instrumental diagnostics (ultrasonography, digital angiography, Angio-TC, MRI) has contributed significantly to improving primary and secondary patency of FAV and early diagnosis of vascular access complications.
In this area, clinical thermography, a noninvasive and nondestructive diagnostic technique for assessing minute surface temperature differences, has shown good potential for the assessment of AVF. In fact, thermographic analysis of a limb site of AVF shows an increase in temperature at the site of the anastomosis and along the course of the arterialized vein.
In this article we report our experience on the use of thermography in preoperative evaluation and postoperative surgical packing of an AVF.
Further studies could validate the use of clinical thermography as a diagnostic technique to be used in the field of hemodialysis vascular accesses.

Keywords: Thermography, Haemodialysis, Arteriovenous Fistula (AVF),   AVF Pre-Postoperative Examination, Post-Operative AVF Management

Sorry, this entry is only available in Italian.

Introduzione

Ogni corpo, a una temperatura superiore allo zero assoluto, emette delle radiazioni nel campo dell’infrarosso. Queste radiazioni non sono visibili ad occhio nudo, ma possono essere captate da una termocamera e rese visibili su un comune schermo LCD. L’intensità delle radiazioni aumenta con l’incremento della temperatura del corpo in esame.

Il corpo umano ha una temperatura media di circa 36,5 °C, una termocamera è quindi in grado di captare le radiazioni emesse e di evidenziare le variazioni di temperatura dei vari distretti corporei.

Esiste una branca della medicina chiamata “termografia clinica” che studia, per mezzo di una termocamera, le variazioni di temperatura del corpo umano indotte da fenomeni fisiologici o patologici. La termografia clinica trova applicazione principalmente nella diagnostica dermatologica, neuropsicologica, angiologica e reumatologica.

La temperatura degli arti è direttamente condizionata dalla circolazione ematica: più un arto è perfuso più è caldo. Questa caratteristica rende gli arti suscettibili allo studio termografico (Figura 1). 

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Prognostic Factors of Peritonitis in Patients on Peritoneal Dialysis: a Retrospective Observational Study

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Stefano Mancin

DOI: 10.69097/41-03-2024-011

Cinzia Fabbri1,2, Elisa La Malfa3, Mattia Ricco3, Lea Godino2,4, Stefano Mancin5, Walter Longo1,2, Giovanni Spadafora1,2, Beatrice Del Grosso3, Marco Sguanci2,6, Maria Pia Zito2, Sergio Cinocca7, Domenica Gazineo2,7

1 Nephrology, Dialysis, Hypertension Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna
2 SIAN, Italian Nephrological Nursing Society, Olbia, Italy
3 Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
4 Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
5 IRCCS Humanitas Research Hospital, Rozzano, Italy
6 Department of Medicine and Surgery, Research Unit of Nursing Science, Università Campus Bio-Medico di Roma, Italy
7 Governo Clinico e Qualità, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy

Corresponding author:
Dr. Stefano Mancin
IRCCS Humanitas Research Hospital,
Via Manzoni 56, 20089
Rozzano, Italia
E-mail: stefano.mancin@humanitas.it

 

Abstract

Background/Objectives. Peritoneal dialysis stands as an established form of renal replacement therapy; yet peritonitis remains a major complication associated with it. This study, analyzing two decades of data from the Nephrology, Dialysis, and Hypertension Division of the University-Hospital IRCCS in Bologna, aimed to identify prognostic factors linked to peritonitis events. It also sought to evaluate the suitability of different peritoneal dialysis techniques, with a focus on Automated Peritoneal Dialysis (APD) and Continuous Ambulatory Peritoneal Dialysis (CAPD). Additionally, the study assessed the impact of an educational program introduced in 2005 on peritonitis frequency.
Methods. Conducting an observational, retrospective, single-center study, 323 patients were included in the analysis, categorized based on their use of APD or CAPD.
Results. Despite widespread APD usage, no significant correlation was found between the dialysis technique (APD or CAPD) and peritonitis onset. The analysis of the educational program’s impact revealed no significant differences in peritonitis occurrence. However, a clear relationship emerged between regular patient monitoring at the reference center and the duration of peritoneal dialysis.
Conclusions. Despite the absence of a distinct association between peritonitis onset and dialysis technique, regular patient monitoring at the reference center significantly correlated with prolonged peritoneal dialysis duration.

Keywords: end-stage renal disease, peritoneal dialysis, peritonitis, peritoneal catheter

Sorry, this entry is only available in Italian.

Introduction

Peritoneal dialysis (PD) is an effective treatment option for patients with end-stage renal disease, particularly for populations such as elderly individuals, diabetics, and those with concomitant pathologies [1, 2]. This technique involves the exchange of solutes and fluids between the patient’s peritoneal capillary blood and the introduced dialysis solution, a process made feasible by the Tenckhoff catheter [3]. This catheter has multiple benefits, including effective fluid exchange, a barrier against infections, and cost-effectiveness [4].

Since 2001, there has been a significant rise in the number of patients opting for dialysis treatments, witnessing an annual growth of approximately seven per cent [5, 6]. This surge can be attributed to an aging population, improved life expectancy for those with end-stage renal disease, and increased access to dialysis for younger patients [7]. The decision between PD and hemodialysis (HD) depends largely on regional and individual circumstances. In developed countries, the choice might be driven by patient preference or accessibility constraints to HD units. In contrast, economic challenges in less affluent regions might render PD as the primary choice [6]. 

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“Green” Hemodialysis: The Centralized Acidic Concentrate from the Dialysis Center of Policlinico of Modena

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Gabriele Donati

DOI: 10.69097/41-03-2024-010

Giuseppe Di Chiaro1*, Gaetano Alfano2*, Ylenia Cancelli1, Floriana Cannito1, Roberto Angelo Pulizzi2, Lucia Stipo2, Fabio Olmeda2, Lucia Palmieri2, Salvatore Perrone2, Vittoria Malaguti2, Gianni Cappelli 1,2, Gabriele Donati1,2

1 Department CHIMOMO, University of Modena and Reggio Emilia, Modena, Italy
2 Nephrology Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy

* Both authors contributed equally as first author

Corresponding author:
Gabriele Donati
Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con interesse Trapiantologico, Oncologico e di Medicina Rigenerativa (CHIMOMO), Università degli Studi di Modena e Reggio Emilia
Largo del Pozzo 71
41125 Modena, Italia
Tel. 0594222485
E-mail: gabriele.donati@unimore.it

 

Abstract

Introduction and aim of the study. The centralized preparation and distribution system of acidic concentrate represents a true innovation in hemodialysis, when compared to acid bags, in terms of convenience and eco-sustainability. The aim of this study is to compare the use of traditional acid bags with the centralized distribution system of acidic concentrate, with particular attention to differences in terms of eco-sustainability and convenience.
Methods. At the Nephrology Dialysis and Renal Transplantation Unit of the University Hospital of Modena was installed the Granumix system® (Fresenius Medical Care, Bad Homburg, Germany). Data collected before the introduction of the Granumix® system (including the used acid bags, boxes and pallets used for their packaging, liters of acid solution used and kilograms of waste generated from wood, plastic, cardboard and residual acid solution) were compared with those collected after the implementation of the Granumix® system. Factors such as material consumption, volume of waste generated, unused and wasted products, time required for dialysis session preparation and nurses’ satisfaction were analyzed to document which system was more environmentally sustainable.
Results. Data collected in 2019 at our Dialysis Center showed a consumption of 30,000 acid bags, which generated over 20,000 kg of waste from wood, plastic and cardboard, and approximately 12,000 liters of residual acid solution to be disposed of, with a handling weight by operators reaching nearly 160,000 kg. The use of the centralized distribution system of acidic concentrate resulted in a significant reduction in waste generated (2,642 kg vs 13,617 kg), residual acid solution to be disposed of (2,351 liters vs 12,100 liters) and weights handled by operators (71,522 kg vs 158,117 kg).
Conclusions. The acidic concentrate appears to be better suited to the sustainability challenge that dialysis must faces today, particularly due to the significant increase in the number of patients, which leads to a higher number of treatments and, therefore, a growing demand for eco-sustainable products.

Keywords: Hemodialysis, Innovation, Sustainability, Acidic Concentrate, Central Dialysis Fluid Delivery System

 

Sorry, this entry is only available in Italian.

Introduzione

Dopo circa 80 anni dal primo trattamento emodialitico, sono tante le sfide che la dialisi deve ancora affrontare. Tra le più importanti va menzionato il significativo trend dell’aumento del numero di pazienti in dialisi che di conseguenza porterà a un aumento nell’utilizzo di risorse naturali e nella produzione di rifiuti [1].  La consapevolezza che la maggior parte dei rifiuti della dialisi viene smaltita senza entrare nel processo del riciclaggio (materiale contaminato da sangue o fluidi biologici, prodotti assimilabili a farmaci) è uno stimolo a una crescente necessità di sviluppare e adottare soluzioni ecosostenibili che riducano l’impatto ambientale e l’inquinamento. Inoltre, l’adozione di soluzioni eco-friendly rappresenta un investimento per le aziende del settore sanitario poiché può generare vantaggi economici nel lungo periodo. Una recente innovazione tecnologica in ambito emodialitico è l’implementazione di un sistema automatizzato per la produzione e distribuzione del concentrato acido.  

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An Unusual Case of Alcoholic Liver Disease Associated with Secondary IgA Vasculitic Nephritis presenting as Rapidly Progressive Glomerulonephritis

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Shruthi Muralidharan

DOI: 10.69097/41-03-2024-09

Shruthi Muralidharan1, Gerry George Mathew1, Varadharajan Jayaprakash1, Sreedhar Sailapathy1

1 SRM, Medical College Hospital and Research Centre

Corresponding author:
Shruthi Muralidharan
8-9E 3 RD PHASE, Wood Creek County, ST
Thomas Mount PO
Chennai 600016
Phone: +91 9884075591
E-mail: shruthi.muralidharan@gmail.com

 

Abstract

IgA nephropathy (IgAN) is a fairly common association with alcoholic liver disease. However, IgA vasculitis (IgAV) is quite an uncommon association with alcoholic liver cirrhosis and only a handful of cases have been reported in literature. Secondary IgAN usually presents in a docile manner, progressing slowly in about 5-25 years. It is usually responsive to steroid therapy, very rarely progressing to End-Stage Renal Disease.

Here, we present a man in his late 50s, a known hypertensive and alcohol related liver-cirrhotic, who presented to our hospital with rash and rapidly progressive renal failure (RPRF). He was diagnosed with IgA nephritis with IgA vasculitis (IgAVN). His diagnosis was confirmed with skin and renal biopsy.

He was started on renal replacement therapy for his renal failure and began oral steroid therapy. After administration of steroid therapy for 6 months, the patient recovered and was dialysis independent with stable renal parameters.

Keywords: IgA nephropathy, Alcoholic Liver disease, rapidly progressive glomerulonephritis, IgA vasculitis

Background

Secondary IgA nephropathy is a well-known complication of alcohol related chronic liver disease [1], however, IgA vasculitis with nephropathy secondary to liver disease is quite rare and only a handful of cases have been reported in literature.

The presentation of IgA nephropathy secondary to liver cirrhosis varies from clinically silent disease to nephrotic or nephritic syndromes [2]. Very rarely, it can present as end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). The natural progression involves development of end stage renal disease within 20 years of presentation [3]. The incidence of rapidly progressive renal failure in IgA nephropathy in less than 10%. 

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Chronic Kidney Disease Eligible for SGLT2 Inhibitors Through the Integration of Italian Administrative and Primary Care Data

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Calabria Silvia

DOI: 10.69097/41-03-2024-08

Carlo Piccinni1, Letizia Dondi1, Silvia Calabria1, Giulia Ronconi1, Antonella Pedrini1, Francesco Lapi2, Ettore Marconi2, Damiano Parretti2, Gerardo Medea2, Gaetano Piccinocchi2, Claudio Cricelli2, Roberto Pontremoli3,4, Nello Martini1, Aldo Pietro Maggioni1,5

1 Fondazione ReS (Ricerca e Salute) – Research and Health Foundation, Roma, Italy
2 Health Search - Istituto di Ricerca della S.I.M.G., Firenze, Italy
3 Dipartimento di Medicina Interna e Specialità mediche, Università di Genova, Italy
4 IRCCS Ospedale Policlinico San Martino, Genova, Italy
5 ANMCO Research Center Heart Care Foundation, Firenze, Italy

Corresponding author:
Silvia Calabria, Pharm D
Fondazione ReS (Ricerca e Salute) – Research and Health Foundation
Via dei Due Macelli, 48 - 00187 Roma, Italy.
Tel.: +39 327 523 7055
Email: calabria@fondazioneres.it
ORCID: 0000-0001-9345-2855

 

Abstract

Background. Patients with chronic kidney disease (CKD) can be successfully treated with sodium-glucose cotransporter-2 inhibitors (SGLT2-Is), regardless of diabetes. Fondazione Ricerca e Salute’s (ReSD) administrative and Health Search’s (HSD) primary care databases were combined in the Database Consortium ReS-HS to quantify and describe patients with CKD potentially eligible for SGLT2-Is and assess costs charged to the Italian National Health Service (SSN).
Methods. Patients aged ≥18 with CKD and estimated glomerular filtration rate (eGFR) <60 ml/min in 2018, without dialysis and/or renal transplantation, were included. HSD was used to develop and validate algorithms for estimating eGFR, based on covariates, within the ReSD. Comorbidities, dispensed drugs, and direct healthcare costs were assessed.
Results. In 2018, 66,297 (5.0% of HSD population) and 211,494 (4.4% of ReSD population) patients with CKD potentially eligible for SGLT2-Is were identified (females ≥58%). Prevalence increased with age with a peak at 75-84 years. Within HSD and ReSD cohorts, respectively: 31.0% and 41.5% had diabetes; in the observation periods, >82% and >96% received ≥1 pharmacological treatment, of which ≥50% and ≥25% received cardiovascular/blood agents and antidiabetics, respectively. From ReSD, mean per capita direct SSN cost was € 3,825 (CI 95%, € 3,655-€ 4,000): 50.1% due to hospitalizations, and 40.2% to pharmaceuticals (31.6% to cardiovascular drugs and 10.1% to antidiabetics).
Conclusion. The Database Consortium ReS-HS methodology found 5% of adult SSN beneficiaries with CKD potentially eligible for SGLT2-Is bringing with them a high cardio-metabolic burden which increases the risk of CKD progression.

Keywords: Sodium-Glucose Transporter 2 Inhibitors, Chronic Kidney Diseases, Primary Care, Health Care Costs, National Healthcare System

This work was supported by an unconditional grant from Astra Zeneca Italy SpA. The financial support for this study was provided with a funding agreement ensuring maintenance of author independence in study design, data interpretation, writing, and decision to publish.

Competing interests: APM received personal fees for the participation in clinical studies supported by Bayer, Novartis, Sanofi and Astra Zeneca, outside the present work. FL and EM and provided consultancies in protocol preparation for epidemiological studies and data analyses for AstraZeneca and Mundipharma. DP, CC, GP and GM provided clinical consultancies for AstraZeneca. RP received honoraria for lectures from Lilly, Boehringer, AstraZeneca, Novo-Nordisk, Vifor, Alfa-Sigma, and Bayer, outside the present work. CP, LD, SC, GR and NM are employees of Fondazione Ricerca e Salute (ReS). AP is consultant for Fondazione Ricerca e Salute (ReS).  

Introduction

Sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) have shown positive outcomes on the reduction of glycated hemoglobin (Hb1cA) levels, the protection from cardiovascular events in high-risk patients with type 2 diabetes mellitus (T2DM), the prevention of cardiovascular death and heart failure regardless of T2DM, and of the progression of chronic kidney disease (CKD) [1, 3]. The latter is likely to be independent from the glucose-lowering effects and favored by the glucose-related natriuresis and osmotic diuresis that reduce intraglomerular pressure; the DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial was based on this hypothesis and aimed at assessing the long-term efficacy and safety of dapagliflozin in patients with CKD, regardless of T2DM [4]. This trial has shown that patients with CKD assessed by an estimated glomerular filtration rate (eGFR) ranging from 25 to 75 ml/min, regardless of T2DM, have benefited from dapagliflozin through a significant reduction of the risk of sustained decline in eGFR of at least 50%, end-stage kidney disease (ESKD) and renal- or cardiovascular-related death [4]. 

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Peritoneal Dialysis Network in North-East Italy: Survey About the Peritoneal Catheter Exit-Site Infection Management and Comparison with ISPD Guidelines

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Antonino Previti

Antonino Previti1, Sabrina Milan Manani2, Vincenzo Cosentini3, Antonina Lo Cicero4, Marta Guizzo5, Apolloni Monica1, Marina Cappellari5, Sabina Rognini3, Mery Zuccolo4, Grazia Maria Virzì6, Giovanni Gambaro7.

1 UOS Nefrologia e Dialisi, Ospedale Alto Vicentino, Santorso (VI)
2 UOC Nefrologia e Dialisi, Ospedale Camposampiero e Cittadella (PD)
3 UOC Nefrologia e Dialisi, Ospedale Fracastoro, San Bonifacio (VR)
4 UOC Nefrologia e Dialisi, Ospedale si Sant’Antonio, San Daniele del Friuli (UD)
5 UOC Nefrologia e Dialisi, Ospedale Castelfranco Veneto, Castelfranco Veneto (TV)
6 UOC Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo Vicenza (VI)
7 UOC Nefrologia e Dialisi, Azienda Ospedaliera Universitaria Integrata Verona, Verona

Corresponding author:
Antonino Previti
UOS Nefrologia e Dialisi, Ospedale Alto Vicentino
Via Garziere, 42
36014 Santorso (VI), Italia
Tel/Fax 0445 571252
E-mail: antonino.previti@aulss7.veneto.it

 

Abstract

Introduction. The Triveneto Peritoneal Dialysis (PD) Network aims to bring together doctors and nurses who deal with PD in a collaborative network in which to exchange mutual knowledge and optimize the use of this method of replacing renal function. A topic of particular interest was the management of peritoneal catheter exit-site infection, given the recent publication of the new guidelines of the International Society of Peritoneal Dialysis (ISPD).
Materials and methods. The survey concerned the criteria for carrying out nasal swab and exit-site, management of exuberant granulation tissue “Proud Flesh”, treatment of exit-site infection (ESI), use of silver dressings, the role of subcutaneous tunnel ultrasound and cuff shaving.
Results. All PD centers in the North-East Italy area have joined the survey with at least one operator per centre. There was a wide variability between the indications for performing the exit-site swab. In the presence of ESI, the prevalent approach is that of oral systemic empiric therapy associated (20.0%) or less (28.9%) with topical therapy, and then adapting it in a targeted manner to the culture examination.
Discussion. From the discussion of the survey emerged the importance of the ESI as an outcome indicator, which allows us to verify whether our clinical practice is in line with the reference standards. It is essential to know and base our activity on what is indicated in national and international guidelines and to document the events that occur in the patient population of each dialysis unit.

Keywords: Peritoneal Dialysis, Exit-site management, Catheter-related Infections, Survey

Sorry, this entry is only available in Italian.

Introduzione

La dialisi peritoneale (PD) è un importante trattamento dialitico domiciliare cui opta quasi un paziente su cinque fra gli afferenti agli ambulatori specialistici nefrologici [1]. Per i pazienti in PD le infezioni correlate al catetere peritoneale (CP) sono tra i principali fattori di rischio di peritoniti, perdita del CP, drop-out dalla metodica. Queste comprendono l’infezione dell’exit-site (ESI) e del tunnel del CP [2].

Il “Network di Dialisi Peritoneale del Triveneto” ha lo scopo di riunire medici e infermieri che si occupano di PD nel Triveneto per la costruzione di una rete collaborativa all’interno della quale sia possibile diffondere la conoscenza e ottimizzare l’impiego di questa metodica sostitutiva della funzione renale. In questi incontri si parte dall’analisi delle evidenze per quindi verificarne l’attuazione nella real life e confrontarle con l’esperienza e i risultati derivanti dalla pratica clinica dei centri dialisi del Triveneto.

Un argomento di particolare interesse è risultato essere la gestione dell’exit-site infetto del CP, soprattutto in considerazione della recente pubblicazione delle nuove linee guida della Società Internazionale di Dialisi Peritoneale (ISPD) [3]. 

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Executive Dysfunction in Patients Undergoing Chronic Haemodialysis Treatment: A Possible Symptom of Vascular Dementia

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Giulia Belluardo

Giulia Belluardo1, Dario Galeano1, Concetto Sessa1, Luca Zanoli2, Walter Morale1

1 O.C Nefrologia e Dialisi, P.O. “Maggiore” di Modica. Azienda Sanitaria Provinciale di Ragusa, Italia
2 Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania, Italia

Corresponding author:
Giulia Belluardo
U.O.C di Nefrologia, Ospedale “Maggiore” Via Aldo Moro n°1,
97015 Modica, Italia
E-mail: belluardogiulia12@gmail.com

 

Abstract

Introduction. Patients undergoing chronic haemodialysis (HD) treatment have an 8-10 times higher risk of experiencing stroke events and developing cognitive impairment. The high vascular stress they are subjected to may be the basis for the development of vascular dementia (VaD).
Objective. The aim of the study is to investigate the executive functions, typically impaired in VaD, of patients undergoing chronic haemodialysis treatment.
Method. HD patients were recruited from the U.O.C. of Nephrology and Dialysis (ASP Ragusa). Risk factors for VaD were collected and then the Frontal Assessment Battery (FAB) was administered.
Results. 103 HD patients were included (males = 63%, age 66 ± 14 years). Risk factors for VaD included a high percentage of patients with anaemia (93%), hypertension (64%) and coronary artery disease (68%).  The cognitive data obtained via FAB show a percentage of 55% deficit scores. All risk factors found a significant association with cognitive scores. Anemia, hypertension, intradialytic hypotension, coronary artery disease, and homocysteine are negative predictors of executive function integrity.
Conclusions. More than half of the patients had deficit scores on the FAB. Reduced cognitive flexibility, high sensitivity to interference, poor inhibitory control and impaired motor programming with the dominant hand were evident. In conclusion, a marked impairment of the executive functions, generally located in the frontal lobes of the brain, was detected in the HD patient, which could be a symptom of a dementia of a vascular nature.

Keywords: hemodialysis, cognitive, impairment, vascular, dementia

Sorry, this entry is only available in Italian.

Introduzione

I pazienti affetti da malattia renale cronica (CKD) sono solitamente più a rischio della popolazione generale di sviluppare deterioramento cognitivo [1], con una prevalenza che varia dal 13% al 58% [2-4]. L’associazione tra malattia renale cronica e funzioni cognitive è stata recentemente indagata e prove collettive dimostrano che una diminuzione del tasso di filtrazione glomerulare stimato (eGFR) aumenta la probabilità di incorrere in deterioramento cognitivo [5, 6]. Sono molti i meccanismi eziopatogenetici sottostanti questo fenomeno, come la disfunzione vascolare, l’infiammazione, l’accumulo di tossine uremiche, l’anemia e le anomalie elettrolitiche [7]. I pazienti in End Stage Renal Disease (ESRD) hanno un rischio maggiore di sviluppare patologie cerebrovascolari e cardiovascolari [8]. In particolare, studi hanno dimostrato che i pazienti allo stadio terminale della malattia e in trattamento emodialitico cronico (HD) hanno un’incidenza di ictus 8-10 volte maggiore rispetto alla popolazione generale, con una prevalenza di ictus emorragico rappresentante il 20% di tutti gli eventi ictali nel dializzato, e presentano una autoregolazione cerebrale alterata [9–12]. Nello specifico, l’emodialisi induce una significativa riduzione del flusso sanguigno cerebrale (CBF) in tutti i lobi durante le sedute emodialitiche [10]. Dunque, l’ingente stress vascolare a cui sono sottoposti questi pazienti potrebbe costituire la base per lo sviluppo del deterioramento cognitivo constatato in questa popolazione e, in particolare, per quadri di demenza vascolare [13].  

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Clinical implications of serum anti-PLA2R levels and glomerular PLA2R deposits in primary membranous nephropathy

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Krishna Chaitanya Gunda

Krishna Chaitanya Gunda1, Gerry George Mathew2, S Balasubramanian3, K S Sunil Kumar4

1 MD, DNB(Nephrology) Consultant Nephrologist, Department of Nephrology, Asian institute of Nephrology and Urology, Nungambakkam, Chennai, Tamil Nadu, India-600034
2 MD, DNB(Nephrology) Associate Professor, Department of Nephrology, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India-603203
3 MD, DNB(Nephrology) Senior Consultant Nephrologist, Department of Nephrology, Apollo hospital, Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006
4 MD, Consultant Pathologist, Department of Pathology, Apollo hospital , Greams lane, 21, Greams road, Thousand lights, Chennai, Tamil Nadu, India-600006

Corresponding author:
Gerry George Mathew
Department of Nephrology,
SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India-603203
Mobile number: +91-8291077361
Email: gerrygeorge007@gmail.com

 

Abstract

Introduction. The clinical implications of serum anti-PLA2R with glomerular PLA2R deposits in primary membranous nephropathy (PMN) is scarcely reported. Hence the study was designed to demonstrate the prevalence of serum anti-PLA2R levels and PLA2R staining in glomeruli in PMN and the clinical implications of the two parameters.
Objectives.

  1. Investigate the prevalence of anti PLA2R positivity in PMN.
  2. Ascertain correlation between serum anti-PLA2R levels and glomerular staining for PLA2R with clinical and lab parameters in PMN.

Patients and Methods. Fifty PMN patients during the period from October 2017 to December 2018 were included. Labs were done and eGFR was calculated as per MDRD 6. Anti-PLA2R titres were done in all patients. Titres more than 20 RU/ml were considered positive. Glomerular staining for PLA2R was graded on fresh frozen tissue by immunofluorescence technique.
Results. Anti-PLA2R antibody positivity and glomerular PLA2R deposition was observed in 42% (21/50) and 86% (43/50) patients respectively. 79.3% (23/29) had positive glomerular PLA2R deposition with negative serum anti PLA2R. Positive correlation were observed between serum PLA2R antibody and serum creatinine (p = 0.0001) and urine protein-creatinine ratio levels with tissue PLA2R staining grades (p = 0.04). Negative association was found between serum albumin (p = 0.026) and tissue PLA2R staining grades.
Conclusion. Serum anti-PLA2R wasn’t a sensitive marker of primary membranous nephropathy in our study group emphasising the need to consider a compendium of serological markers for diagnosis of primary membranous nephropathy and to rely more on glomerular deposition of PLA2R as a better clinical indicator for PMN.

Keywords: anti-PLA2R, Membranous Nephropathy, Glomerular PLA2R deposits, Tissue PLA2R staining, Nephrotic Syndrome

Introduction

Membranous nephropathy (MN) is an important aetiology of adult onset nephrotic syndrome which is subclassified into primary (PMN) and secondary membranous nephropathy. Secondary membranous nephropathy is implicated in clinical scenarios such as cancer, autoimmune diseases and infections [1, 2]. PMN can be diagnosed on the basis of biomarkers like Anti PLA2R levels which can be useful in adjusting the therapeutic initiatives for management of the disease process. These biomarkers may be used to predict clinical consequences like decreased eGFR or proteinuria [3]. The discovery of phospholipase A2 receptor (PLA2R) antibody has contributed to an improvised understanding of the pathophysiology of PMN [4]. The specificity and sensitivity of PLA2R antibody for the PMN has been approximated to be around 100% [5] and 50% to 80% respectively [6]. Previous studies have tried to assess the utility of antibodies to PLA2R in clinical practice. However, there is a definite need for more studies to study the prevalence of glomerular PLA2R deposits, so that it can be applied as a diagnostic and prognostic test in the patients with PMN. 

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