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INTRODUCTION Demographic analysis shows the ageing of the global population and the consequent increase in the age of hospitalized subjects and of patients starting dialysis. Hence, interest in the feasibility, safety, and usefulness of renal biopsy in elderly patients is growing. We examined the data of 131 patients over the age of 75 who underwent renal biopsy. We analyzed the safety of the procedure, treatment, and outcomes. RESULTS Histological diagnoses included: membranous glomerulonephritis (GN) 20.6%, crescentic GN 12.9%, IgAGN 10.6%, focal segmental glomerulosclerosis 9.1%, acute GN 4.5%, amyloidosis 9.1%, and acute tubular necrosis 3.8%. Mean glomerular obsolescence was 28.9 Â ± 27.9%. Mean age of the patients was 78.7 Â ± 5.73 years. At the time of biopsy, serum creatinine (SCr) was 4.47 Â ± 2.56 mg/dL and proteinuria was 4.82 Â ± 6.78 g/day. Targeted treatment was given to 51.9% of patients, 52.9% of whom had a good clinical response. Eight patients had clinically non-relevant side effects (11.7%). A positive response (defined as a more than 50% reduction of SCr, or by partial or complete remission of proteinuria) was observed in 36 patients (52.9%). 76 patients were monitored for 57 Â ± 9.89 months: 18 patients were on dialysis (follow-up 2.56 Â ± 3.61 months), 15 died (follow-up 58.5 Â ± 13.43 months), and 52 remained under nephrologic observation for 36 Â ± 31 months (SCr was 2.56 Â ± 0.75 mg/dL and proteinuria was 4.82 Â ± 6.78 g/day). CONCLUSION In our experience, renal biopsy is safe even in very elderly patients; it allowed targeted treatment in 51.9% of patients, 52.9% of whom had a good clinical response, possibly contributing to prolonged patient survival and improved quality of life.

Volume overload is typical of haemodialysis patients; correct volume status evaluation is crucial in achieving blood pressure homeostasis, hypertension management and good treatment planning. This study evaluates the effect of acute volume depletion on ultrasonographic parameters and suggests two of them as able to predict patients volume overload.27 patients with end stage renal disease treated with haemodialysis underwent a complete echocardiographic exam before, after 90 min and at the end of the dialysis.Blood pressure levels significantly drop during the first 90 min of dialysis (139 ± 20 vs 126 ± 18; p0.0001), reaching a steady state with significantly lower values compared to baseline (130 ± 28; p = 0.02). LV and left atrial volume significantly decreased (baseline vs end dialysis 98 ± 32 vs 82 ± 31 p = 0.003 and 28 ± 10 vs. 21 ± 9 cc/m(2) p0.001). A significant reduction of systolic function (EF 61.6 % ± 9 vs 58.7 % ± 9 p = 0.04), of diastolic flow velocities (E/A 1.13 ± 0.37 vs. 0.87 ± 0.38 p0.001) and mitral annulus TDI tissue velocity (i.e. E' lat 10.6 ± 3 vs. 9.4 ± 3 cm/s; p 0.0001) were observed. Stroke work (SW) and LV end-diastolic diameter (LVEDd) indexed to height 2.7(LVEDdi) were able to predict volume overload: cut off values of respectively 13.5 mm/m(2.7) for LVEDdi and 173 cJ for SW were able to predict with a specificity of 100 % the presence of a volemic overload of at least 4 %.Blood pressure, cardiac morphology and function are significantly modified by acute volume depletion and such variations are strictly interrelated. SW and LVEDd/height(2.7) may identify ESRD patients carrying an higher volume load.

BackgroundIntradialytic hypotension (IDH) is still a major clinical problem for haemodialysis (HD) patients. Haemodiafiltration (HDF) has been shown to be able to reduce the incidence of IDH.MethodsFifty patients were enrolled in a prospective, randomized, crossover international study focussed on a variant of traditional HDF, haemofiltration with endogenous reinfusion (HFR). After a 1-month run-in period on HFR, the patients were randomized to two treatments of 2 months duration: HFR (Period A) or HFR-Aequilibrium (Period B), followed by a 1-month HFR wash-out period and then switched to the other treatment. HFR-Aequilibrium (HFR-Aeq) is an evolution of the haemofiltration with endogenous reinfusion (HFR) dialysis therapy, with dialysate sodium concentration and ultrafiltration rate profiles elaborated by an automated procedure. The primary end point was the frequency of IDH.ResultsSymptomatic hypotension episodes were significantly lower on HFR-Aeq versus HFR (23 ± 3 versus 31 ± 4 of sessions, respectively, P l l0.03), as was the per cent of clinical interventions (17 ± 3 of sessions with almost one intervention on HFR-Aeq versus 22 ± 2 on HFR, P, SCOPUS: ar.j, info:eu-repo/semantics/published

The kidneys are a major target of PAPS. The histologic lesions of PAPS nephropathy are vascular; among them thrombotic microangiopathy (TMA) is the most characteristic. It is still not clear in the literature whether the nephropathy can be the unique manifestation of PAPS in the absence of other thrombotic processes; that is: do the renal microthrombotic lesions allow to make the diagnosis of PAPS in presence of anti-phospholipid antibodies (APA)? With this purpose we present three clinical cases. The first patient had severe hypertension C4 hypocomplementemia, thrombocytopenia, and mitralic valve insufficiency. LAC and anti-cardiolipin antibodies at high titre were positive. The histologic picture was characterized by basement membrane reduplication and arteriolar mucoid degeneration, which are features of early phase of TMA. The second patient had severe hypertension. The detection of anti-cardiolipin antibodies was performed several times and resulted positive three times, four months after the diagnosis as well. The renal histologic features were consistent with late lesions of TMA. The third patient had severe hypertension, rapidly progressive renal failure, tricuspidal valve insufficiency and two positive anti-phospholipid antibodies determinations three weeks apart (in two occasions anti-cardiolipin and in one occasion LAC as well were found). The renal lesions were characteristic for TMA. In conclusion we think that patients with TMA and antiphospholipid antibodies can be considered affected by PAPS, as the thrombotic process is represented by thrombosis in preglomerular arterioles, which leads to TMA.

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

The aim of this study was the detection of HCV viremia in both anti-HCV antibody positive and negative hemodialysis patients. Sera from 75 patients on extracorporeal blood purification in the same dialysis unit were analyzed. Anti-HCV antibodies were detected using a 2nd-generation ELISA assay and in all positive cases a RIBA 3rd-generation test was performed. HCV-RNA was tested by a reverse transcription-nested polymerase chain reaction (RT-PCR) assay with primers located in the 5' region. PCR products were analyzed by a nonradioactive hybridation assay. The presence of anti-HCV antibodies was detected in 30 (40%) patients by means of ELISA II test; 28 of them were RIBA III positive and two indeterminate. Twenty-four of the 30 HCV Ab ELISA II positive patients (80%) were HCV-RNA positive (23 RIBA III positive and 1 indeterminate). Six anti-HCV Ab ELISA II positive patients tested negative for HCV-RNA (20%); 5 of these patients were also positive for anti-HCV antibodies with a RIBA III test and 1 was indeterminate. None of the anti-HCV negative patients was HCR-RNA positive. In two cases we documented the disappearance of viremia after an acute HCV infection, with the persistence of antibody reactivity. In conclusion, anti-HCV antibody positive hemodialysis patients should be considered as potentially infectious.

Background Acute pyelonephritis (APN) is a common disease which rarely evolves into abscesses. Methods We prospectively collected clinical, biochemical and radiological data of patients hospitalized with a diagnosis of APN from 2000 to 2008. Results Urinary culture was positive in 64/208 patients (30.7%) and blood cultures in 39/182 cases (21.4%). Two hundred and thirteen patients were submitted to computed tomography (CT) or nuclear magnetic resonance (NMR): confirmation of APN was obtained in 196 patients (92%). Among these, 46 (23.5%) had positive urine culture, 31 (15.8%) had positive blood culture and 15 (7.6%) had positive cultures of both urine and blood. In 98 patients, either urine or blood cultures were negative, but CT/NMR were positive for APN. Fifty of the 213 patients submitted to CT/NMR (23.5%) had intrarenal abscesses: only 2 were evidenced by ultrasound examination. No differences were found between patients with positive or negative CT with regards to fever, leucocytosis, C-reactive protein, pyuria, urine cultures and duration of symptoms before hospitalization. No differences were found between patients with or without abscesses with regards to these parameters and risk factors. Patients with abscesses had a longer duration of treatment and hospitalization. Conclusions Our data suggest that in APN it is not always possible to routinely document urinary infection in a clinical setting. This finding could be explained by previous antibiotic treatment, low bacterial growth or atypical pathogens. Systematic CT or NMR is necessary to exclude evolution into abscesses, which cannot be suspected on clinical grounds or by ultrasound examination and may also develop in the absence of risk factors.

Central venous accesses have become an integral component of vascular access procedures for hemodialysis. Although the DOQI guidelines recommend that less than 10% of chronic hemodialysis patients should be maintained on catheters, in some countries higher prevalences are reported, as in the United States and the United Kingdom (18% and 24%, respectively, according to the DOPPS). The native arteriovenous fistulas are still the best suited accesses for hemodialysis. However, this option is impractical in many situations, so that several justifiable reasons exist for protracted dialysis catheter use; these include the catheter as a bridge angioaccess device, while the patient is awaiting living-related kidney donor transplantation or maturation of an autologous fistula or graft or, increasingly, as the permanent vascular access for patients with unsuitable vascular anatomy who have exhausted all other options. Moreover, the surgical creation of an AVF is felt to be impossible or at least seems to entail significant risks in situations of high output cardiac failure, myocardial ischaemic events and steal syndrome. In these cases, the dialysis access catheter brings considerable advantages, but it also carries tremendous drawbacks. In addition to the increased risk of luminal thrombosis, infection, unreliable blood flows, central venous stenosis, shorter use life and patient cosmetic concern, tunneled catheters are associated with an increased risk of death. Tunnellization, exit site protection, antibiotic-coated or antiseptic-impregnated hemodialysis catheters, antibiotic lock solutions could be helpful in preventing and treating catheter-related bacteremias. Moreover, the development of a subcutaneous port, that is durable, offers a high blood flow and is fully implantable subcutaneously, may become an alternative for chronic use. In our 10-year experience we implanted in our center over 450 central venous catheters with a satisfactory survival (86% at 1 year and 79% at 2 years for the subcutaneous port). In a matched comparison between Tesio twin catheters and Dialock ports (37 vs. 35, respectively), followed for a 2 year period, no significant differences emerged as regards bacteremia incidence, 0.58/1,000 catheter-days in the Tesio catheter group vs. 0.9/1000 catheter-days in the subcutaneous port group, p=0.12; thrombolytic agents needed, 4.5% vs 4.3% of dialysis sessions; or access failure with removal of the device, 8.1% vs 14.2%, p=0.4. The longer duration of antibiotic therapy in the Tesio group (24.6 vs 14.3 days, p=0.006) was due to the higher incidence of cutaneous infectious episodes (3.8 vs 0.16/1,000 catheter-days). In conclusion, although central venous catheter is the vascular access of last choice, in particular cases it can be a useful alternative, provided that strict protocols for nursing care and proper catheter management are implemented in every center.

Clinical and therapeutic characteristics of chronic dialysis patients vary widely at national and/or regional levels. Their increased cardiovascular (CV) mortality is not explained by traditional cardiovascular disease (CVD) risk factors only. Therefore, this study aimed to investigate and compare the characteristics of patients starting dialysis in a homogeneous Alpin region and possibly to identify new biological parameters (phenotypes or genotypes), which eould be responsible for the increased CVD seen in end-stage renal disease (ESRD) patients.A cohort of 279 non-selected consecutive patients entering a dialysis program was prospectively investigated in eight centers of three adjacent regions in France, Italy and Switzerland. In addition to the usual demographic, clinical and biological data, we analyzed at study entry the blood levels of homocysteine, lipoprotein(a) (Lp(a)) and antioxidized low density lipoprotein (LDL) antibodies, vitamin B12 status, Lp(a) and haptoglobin phenotypes, methylenetetrahydrofolate reductase (MTHFR), angiotensin-converting enzyme (ACE), allele epsilon E4 of apolipoprotein (ApoE4) and plasminogen activator inhibitor-1 (PAI-1) genetic polymorphism.At entry, 90.3% of patients were hypertensive, 30% had type 2 diabetes mellitus and 17.6% were current smokers; 42% of patients had already experienced at least one CV event: peripheral artery disease (26% of the cohort), coronary artery disease (22%) or ischemic cerebro-vascular disease (16%). Forty-two patients had hador =2 CV events or documented atherosclerotic localizations. Anemia was not optimally treated: mean hemoglobin (Hb) was at 97.7 g/L and, while overall 62% of patients received erythropoietin (EPO) prior to dialysis, large national differences were observed. Compared to the reference population, ESRD patients exhibited increased homocysteinemia, Lp(a) levels and ApoE4 allele prevalence. Conversely, the distribution of Lp(a) phenotype, MTHFR TT, ACE DD and PAI-1 4G/4G was equivalent to that of the reference population. In addition, none of the analyzed phenotypical or genotypical parameters, except for the haptoglobin 2.2 phenotype, could be associated with the existence of a previous adverse CV event.(1) The clinical characteristics of the ESRD patients entering dialysis in our region were comparable to the currently observed dialysis populations in most European countries with the deleterious role of advancing age, diabetes, previous CVD, smoking and hypertension evident (2). Except for anemia therapy, there were no regional or national differences observed at dialysis start. (3) An analysis of the phenotypic and genotypic CV risk factors demonstrated differences with the reference population only for hyperhomocysteinemia, Lp(a) and ApoE4 allele prevalence, with no notable differences among the participating centers.

Cardiovascular disease accounts for almost half of the total mortality in patients with end stage renal disease (ESRD). It has recently been debated whether coronary revascularization has the same rate of risks and successes in this cohort of patients compared to patients without renal disease. Since 1991, 17 dialysis patients were submitted to coronary revascularization in our center. Seven patients were following peritoneal, 10 hemodialytic treatment. Four patients were submitted to percutaneous transluminal coronary angioplasty (PTCA) and 13 to surgical revascularization (CABG). In 2 patients the coronary lesion was unique, in the others stenosis of multiple vessels were found. Six patients were diabetic. The mean age at the onset of the coronary artery disease (CAD) was 57.17 +/- 11.6 years. The mean time elapsed from the onset of the CAD and the performance of the PTCA or CABG was 30.1 +/- 35.4 months. The mean time from beginning of dialysis treatment to revascularization was 48.2 +/- 39.6 months. Mean hemoglobin values were 9.7 +/- 1 g/dL, mean phosphorus values were 5.2 +/- 8.7 mg/dL, mean cholesterol values were 211 +/- 49.5 mg/dL. The procedure was technically successful in all patients. Mean survival was 25.09 +/- 28.12 months. Twelve patients died, 5 of whom within one month. Survival at one month was 70.5%, at 6 months 58.8%, at one year 52.9%, at 2 years 47%. There was neither significant difference patients submitted to PTCA and those submitted to CABG, nor between diabetic and non-diabetic patients. In conclusion, coronary revascularization in our experience is a high risk procedure in dialysis patients. The reasons for this could be the severe general conditions of these patients affected with diffuse vasculopathy and the long time elapsed since the onset of the ischemic cardiopathy. Thus, our results could suggest the opportunity of performing earlier screening of coronary situation and revascularization treatment in CAD dialysis patients.

dialysis strategies and pharmacological management of hypertension. Background. The tenet that peritoneal dialysis is capable of either normalizing or improving blood pressure Key words: ambulatory blood pressure monitoring; control in uraemic patients is based on outdated or antihypertensive therapy; prevalence of hypertension; monocentric experiences. Therefore, we assessed the peritoneal dialysis; white-coat hypertension prevalence of hypertension and the eYcacy of antihypertensive therapy in a large, multicentric cohort of patients on peritoneal dialysis. Methods. Twenty seven out of the 50 centres belonging Introduction to the Italian Co-operative Peritoneal Dialysis Study Group took part in the study. The main patient Cardio- and cerebrovascular events are the main causes selection criteria were: peritoneal dialysis therapy for of morbidity and mortality of patients on peritoneal at least 3 months and no peritonitis or changes in dialysis [1]. Although high blood pressure (BP) is the dialysis technique for at least 1 month. Clinical blood leading factor causing cardiovascular mortality in the pressure was measured according to WHO/ISH general population, scant attention is paid to arterial guidelines. Ambulatory blood pressure monitoring hypertension in recent peritoneal dialysis studies. This was carried out using a SpaceLabs 90207 recorder. might be due to the general belief that end-stage renal Hypertension was defined according to WHO/ISH disease (ESRD)-related hypertension is easily concriteria and staged according to the criteria of the Joint trolled by peritoneal dialysis. Unfortunately, this asserNational Committee on Detection, Evaluation and tion is at least in part based on outdated reports [2]. Treatment of High Blood Pressure (JNC ), 5th Report. In recent years, ambulatory blood pressure monitoring Ambulatory blood pressure monitoring recordings has been applied in peritoneal dialysis patients. This were used to evaluate white-coat hypertension, blood evaluation technique oVers some advantages over trapressure load and the dipping phenomenon. ditional oYce measurement as it avoids ‘observer bias’, Results. Five hundred and four subjects were evalu- ‘digit preference’ of the operator and the stress reaction ated. Hypertension was prevalent in 88.1% of the of the patient, and provides mean BP levels represpopulation, and 362 out of 444 hypertensive patients enting the average of >90 measurements per day. were on antihypertensive therapy. JNC staging Nonetheless, only a few small studies have been carried revealed that 188 patients had moderate to severe out using ambulatory blood pressure monitoring in hypertension. Blood pressure load was pathological in peritoneal dialysis patients [3]. 77.3% of the patients receiving antihypertensive treat- We were thus prompted to conduct a large multicenment. White-coat hypertension was identified in 9.1% tre study to evaluate the prevalence of hypertension of the hypertensive patients not on antihypertensive and the eYcacy of antihypertensive therapy in peritontherapy, and 53.1% of the patients were non-dippers. eal dialysis patients using traditional clinical sphygmoConclusions. The study demonstrates that hyper- manometric measurements and 24 h ambulatory blood tension is a dramatic, unsolved problem in uraemic pressure monitoring recordings. patients treated with peritoneal dialysis, and casts doubts on the eVectiveness of our current peritoneal Subjects and methods

Increased sodium-lithium countertransport activity in red cells of IgA nephropathy patients. The aim of this work was to analyze Na,Li countertransport activity in the erythrocytes from patients with IgA nephropathy, in relationship with their blood pressure status and lipid profile Forty-nine patients (32 males, 17 females) with biopsy-proven IgA nephropathy and without significant impairment of renal function (serum creatinine ≤ 1.4 mg/dl) and 36 normal subjects (21 males, 15 females) were evaluated Twenty-nine patients with IgA nephropathy were normotensive and 20 hypertensive (diastolic pressure ≥ 95 mm Hg or treated by antihypertensive drugs). Na,Li countertransport was significantly higher in red cells from hypertensive than from normotensive patients (P = 0.002) and normal subjects (P = 0.0001), (values respectively 309 ± 17; 241 ± 12 and 211 ± 11 µmol/liter RBC/hr); normotensive patients with IgA nephropathy did not differ from controls regarding the Na,Li countertransport rate. A multiple stepwise logistic regression analysis with blood pressure status as the dependent variable and Na,Li countertransport activity, age, serum creatinine, proteinuria, cholesterol, triglycerides, plasma potassium and time from onset as independent variables, indicated an independent significant association for Na,Li countertransport (P = 0.002) proteinuria (P = 0.006), plasma potassium (P = 0.006) and age (P = 0.029). Other tested variables were not independently related to blood pressure status. Hyperlipidemic patients (plasma total cholesterol concentration >200 mg/dl and/or plasma triglycerides >172 mg/dl) had an erythrocyte Na,Li countertransport activity significantly higher than normolipidemic (P = 0.005) and controls (P = 0.001) (values respectively 295 ± 14; 226 ± 12 and 211 ± 11 µmol/liter RBC/hr). A high erythrocyte Na,Li counter-transport rate may be a marker of an increased risk of developing arterial hypertension, lipid abnormalities, and perhaps a more severe renal disease in IgA nephropathy.

Erythrocyte Na,K pump activity and arterial hypertension in uremic dialyzed patients. We have evaluated in 26 uremic patients [21 on hemodialysis, 5 on continuous ambulatory peritoneal dialysis (CAPD)], 11 normotensive, and 15 hypertensive (MAP > 110mm Hg) patients the following properties: a) erythrocyte (RBC) Na concentration [Nai] and ouabain-sensitive and -resistant Na effluxes; b) the effect of uremic sera on ouabain-sensitive Na efflux in normal RBC; c) serum digoxin-like immunoreactivity; d) cardiac index and total peripheral resistance. In 19 healthy subjects a) and c) were also evaluated. RBC Na,K pump activity was lower in uremic patients than in normal subjects (P < 0.0005), and lower in hypertensive (P < 0.02) than in normotensive patients. Serum from uremic patients inhibited ouabain-sensitive Na efflux in normal RBC, the inhibition being correlated with both the rate constant for ouabain-sensitive Na efflux (r = -0.67; P < 0.005) and [Nai] (r = 0.43; P < 0.05) of RBC of patients from whom the serum was obtained. Inhibition of ouabain-sensitive Na efflux was significantly higher with serum from hypertensive than from normotensive patients (P < 0.05). Serum digoxin-like immunoreactivity was present in all uremic patients (0.402 ± 0.054 ng/ml in normotensive and 0.428 ± 0.040 ng/ml in hypertensive, P = ns), while it was not detectable in normal subjects. Hypertensive patients had peripheral resistance significantly higher than normotensive (P < 0.05), while cardiac index was similar in both groups. A strong inverse correlation was found between the rate constant for ouabain-sensitive Na efflux in RBC and total peripheral resistance (r = -0.76; P < 0.0001). In conclusion: 1) Hypertensive uremic dialyzed patients have lower erythrocyte Na,K pump activity as compared with normotensive, and higher levels of a specific circulating Na,K pump inhibitor; 2) reduced sodium transport by Na,K pump is strongly correlated with increased total peripheral resistance, thus suggesting a role in the pathogenesis of arterial hypertension in patients with chronic uremia undergoing hemodialysis or CAPD; 3) a digoxin-like immunoreactive material is detectable in uremic sera, but it does not have a close relationship to Na,K pump inhibitor.