Search

Background: Few reports have addressed the change in renal replacement therapy (RRT) management in the Intensive care Units (ICUs) over the years in western countries. This study aims to assess the trend of dialytic practice in a 4.5-million population-based study of the northwest of Italy., Methods: A nine-year survey covering all the RRT provided in the ICUs. Consultant nephrologists of the 26 Nephrology and Dialysis centers reported their activities in the years 2007, 2009, 2012, and 2015., Results: From 2007 to 2015 the patients treated increased from 1042 to 1139, and the incidence of RRT from 254 to 263 cases/10^6 inhabitants. The workload for dialysis center was higher in the larger hub hospitals. RRT for acute kidney injury (AKI), continuation of treatment in chronically dialyzed patients, or extrarenal indications accounted for about the stable rate of 70, 25 and 5% of all RRT sessions, respectively. Continuous modality days increased from 2731 days (39.5%) in 2007 to 5076 (70.6%) in 2015, when the continuous+prolonged treatment days were 6880/7196 (95.6% of total days). As to RRT timing, in 2015 only the classical clinical criteria, and no K-DIGO stage were adopted by most Centers. As to RRT interruption, in 2015 urine volume was the first criterion. Implementation of citrate anticoagulation (RCA) for RRT patients significantly increased from 2.8% in 2007 to 30.9% in 2015, when it was applied in all 26 Centers., Conclusions: From 2007 to 2015, current practice has changed towards shared protocols, with increasing continuous modality and RCA implementation.

Objectives: To investigate the effects of long-term use of the lower lingual arch (LLA) on the sagittal and vertical positions of the permanent lower incisors and first molars., Materials and Methods: The sample consisted of 98 patients who were treated with an LLA (LLA group) and 39 patients who were treated without an LLA (no-LLA group). The positional changes of the lower incisors and first molars were analyzed after performing mandibular structural superimpositions on lateral cephalometric radiographs taken before treatment (T1) and at the end of LLA therapy (T2). The mean ages at T1 and T2 were 8.5 years and 13.2 years, respectively. Study casts were analyzed to quantify arch dimensional changes., Results: Mesial movement of the lower molar cusp was similar between the LLA and no-LLA groups, but the vertical position was slightly greater at T2 in the LLA group. In the LLA group, there was a molar tip-back effect, and the lower incisors were proclined 4.2° more than in the no-LLA group. Arch perimeter decreased 3.6 ± 2.6 mm without an LLA and 0.97 ± 3.7 mm with an LLA. Intercanine and intermolar widths both increased about 1 mm more with an LLA (P < .0001)., Conclusions: The LLA does not seem to restrict mesial movement and vertical eruption of the lower incisors and molars in the long term. The LLA effectively preserves the arch perimeter at the expense of a slight lower incisor proclination., (© 2022 by The EH Angle Education and Research Foundation, Inc.)

Fly ash from municipal solid waste incineration (MSWI-FA) contains leachable heavy metals. In the present study the correlations between heavy metal content, particle size, speciation distribution with respect to water leaching are investigated, using a combination of solid-state bulk analytical techniques, leaching treatments, sequential extractions and thermodynamic geochemical modelling. Among the analyzed heavy metals, Zn and Pb are the most abundant in any grain size class, followed by Cu, Cr, Cd and Ni, with concentration that tends to increase with a decrease of the grain size. The phase composition is constituted of salt (halite, sylvite, anhydrite and syngenite), which provide the main minerals regardless of the particle size class; calcite, quartz and gehlenite occur in comparatively lower amounts, while 50% wt is composed of amorphous fraction. Heavy metal leaching is strongly correlated to speciation distribution, and in particular to the fraction (F1) associated with salt, carbonate and weak surface sorption. Leaching from speciation due to surface complexation on Al/Fe (hydr)oxide becomes relevant at acidic regime. Particle size and heavy metal content, in turn, moderately correlate with leaching. The F1-speciation as a function of particle size does not exhibit a definite trend shared by all heavy metals under investigation. This suggests that i) differences in speciation distribution, rather than bare heavy metal content or particle size, govern leaching from MSWI-FA; ii) F1 can be regarded as a marker of the potential heavy metal leaching; iii) a comparatively modest efficiency in managing MSWI-FA is expected from grain size separation strategies., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: No agent has yet been proven to be effective for the treatment of patients with severe COVID-19., Methods: We conducted a pilot prospective open, single-arm multicentre study on off-label use of tocilizumab (TCZ) involving 63 hospitalised adult patients (56 males, age 62.6±12.5) with severe COVID-19. Clinical and laboratory parameters were prospectively collected at baseline, day 1, 2, 7 and 14. No moderate-to-severe adverse events attributable to TCZ were recorded., Results: We observed a significant improvement in the levels of ferritin, C-reactive protein, D-dimer. The ratio of the partial pressure of oxygen (Pa02) to the fraction of inspired oxygen (Fi02) improved (mean±SD Pa02/Fi02 at admission: 152±53; at day 7: 283.73±115.9, at day 14: 302.2±126, p<0.05). The overall mortality was 11%; D-dimer level at baseline, but not IL-6 levels were predictors of mortality. TCZ administration within 6 days from admission in the hospital was associated with an increased likelihood of survival (HR 2.2 95%CI 1.3-6.7, p<0.05)., Conclusions: In hospitalised adult patients with severe COVID-19, TCZ could be a safe option. An improvement in respiratory and laboratory parameters was observed. Future controlled trials in patients with severe illness are urgently needed to confirm the definite benefit with IL-6 target therapy.

The aim of this study is twofold: (i) characterization of the bottom ashes from the Incinerator plant of the city of Turin (northern Italy), in terms of their chemical/phase compositions and capacity to release heavy metals in leachates, as a function of particle size; (ii) investigation of thermal treatments' efficacy to promote inertization of the same bottom ashes, exploring time-temperature ranges with t ≤ 6 h and T ≤ 1000 °C. Special attention is paid to macro-sampling techniques in order to have samples that are representative of the average bottom ashes production. Micro-XRF, ICP-OES, SEM-EDS, Ion Chromatography and X-ray powder diffraction were used to investigate bottom ashes and leachates. Bottom ashes are mainly constituted by an amorphous phase, ∼66-97 wt%, regardless of particle size; the remaining phases are quartz, calcite, Fe-oxides, melilite and other minor crystalline materials. The amorphous phase exhibits a relevant dependence on particle size, and undergoes dissolution in water up to 20 wt%, thus being the most important component in affecting chemical species release. The smaller the bottom ashes' particle size, the more the heavy metals (major species: Zn, Cu, Ti, Pb) and calcium contents increase, whereas silicon's decreases. Electrolytic current observations in combination with phase/chemical composition and metals release as a function of particle size, suggest that bottom ashes partition into two classes, i.e. ≥1 and <1 mm, for inertization purposes. Thermal treatments exhibit partial efficacy to curb heavy metals mobility: whilst they reduce Cu release, they lead to a inverse effect in the case of Cr., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

We describe factors associated to renal infarction, clinical, instrumental and laboratoristic features, and therapeutic strategies too. This is an observational, review and polycentric study of cases in Nephrologic Units in Piedmont during 2013-2015, with diagnosis of renal infarction by Computed Tomography Angiography (CTA). We collected 48 cases (25 M, age 57±16i; 23 F age 70±18, p = 0.007), subdivided in 3 groups based on etiology: group 1: cardio-embolic (n=19) ; group 2: coagulation abnormalities (n= 9); group 3: other causes or idiopathic (n=20). Median time from symptoms to diagnosis, known only in 38 cases, was 2 days (range 2 hours- 8 days). Symptoms of clinical presentation were: fever (67%), arterial hypertension (58%), abdominal o lumbar pain (54%), nausea/vomiting (58%), neurological symptoms (12%), gross hematuria (10%). LDH were increased (>530 UI/ml) in 96% of cases (45 cases out of 47), PCR (>0.5 mg/dl) in 94% of cases (45 out of 48), and eGFR <60 ml/min in 56% of cases (27 out of 48). Comparison of the various characteristics of the three groups shows: significantly older age (p=0.0001) in group 1 (76±12 years) vs group 2 (54±17 years) and group 3 (56±17 years); significantly more frequent cigarette smoking (p = 0.01) in group 2 (67%; 5 cases out of 9) and group 3 (60%; 12 cases out of 20) than group 1 (17%). No case has been subjected to endovascular thrombolysis. In 40 out of 48 cases, anticoagulant therapy was performed after diagnosis: in 12 (32%) cases no treatment, in 12 cases (30%) heparin, in 8 cases (20%) low molecular weight heparin, in 4 cases (10%) oral anticoagulants, in 3 cases fondaparinux (7%), in 1 case (2%) dermatan sulfate., Conclusions: Although some characteristics may guide the diagnosis, latency between onset and diagnosis is still moderately high and is likely to affect timely therapy., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Background: Metformin-associated lactic acidosis (MALA) is a severe complication of drug administration with significant morbidity and mortality. So far no study in large population areas have examined the incidence, clinical profile and outcome of acute kidney injury (AKI)-MALA patients admitted in intensive care units (ICUs) and treated by renal replacement therapy (MALA-RRT)., Methods: Retrospective analysis over a 6-year period (2010-2015) in Piedmont and Aosta Valley regions (5,305,940 inhabitants, 141,174 diabetics treated with metformin) of all MALA-RRT cases., Results: One hundred and seventeen cases of AKI-MALA-RRT were observed (12.04/100,000 metformin treated diabetics, 1.45% of all RRT-ICU patients). Survival rate was 78.3%. The average duration of RRT was 4.0 days at mean dialysis effluent of 977 mL/kg/day. At admission most patients were dehydrated, and experienced shock and oliguria., Conclusion: Our data showed that MALA-RRT is a common complication, needing more prevention. Adopted policy of early, extended, continuous and high efficiency dialysis could contribute to an observed high survival rate. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=471917., (© 2017 S. Karger AG, Basel.)

We analyzed the clinical features and the factors associated with the presence of hyperkalemia (serum potassium >5.3 mmol/L) in a cohort of patients presenting to an Emergency Department. A total of 168 cases were observed (89 males and 79 females), mean age 77.512 years. Fifty-six patients were diabetics (33.3%), 51 patients had chronic kidney disease (30%) and 36 patients with cardiac failure (21.4%). Sixty-nine patients (41%) were treated with RAS-blockers (ACE-I n = 50; ARBs, n = 19). 65 subjects were taking loop diuretics (39%), 17 (10%) thiazides. Thirty-one (18%) were assuming antialdosterone drugs; 16 (52%) out of these had a positive history of heart failure and 14 (41%) had a positive history of chronic kidney disease. In 85 cases (51%) patients were receiving an ACE/ARB or an antialdosterone drug. In 125 patients (74%) eGFR at presentation was <60 ml/min/1.73 m2. Serum potassium values were significantly higher in patients treated with both ACE/ARB and antialdosterone drugs. In 20 cases (12%) serum potassium was 6.5 mmol/L; these patients assumed antialdosterone drugs more frequently, alone and mostly in association with ACE-I/ARBs (65% vs 7%; p<0.0001). The simultaneous assumption of ACE-I/ARBs and antialdosterone drugs emerges as the major cause of severe hyperkalemia in our cases, thus confirming the warnings about this association in the presence of advanced age and reduced glomerular filtration rate.

Objective: To consider the effectiveness of early treatment using one mixed-dentition approach to the correction of moderate and severe Class II malocclusions., Materials and Methods: Three groups of Class II subjects were included in this retrospective study: an early treatment (EarlyTx) group that first presented at age 7 to 9.5 years (n = 54), a late treatment (LateTx) group whose first orthodontic visit occurred between ages 12 and 15 (n = 58), and an untreated Class II (UnTx) group to assess the pretreatment comparability of the two treated groups (n = 51). Thirteen conventional cephalometric measurements were reported for each group and Class II molar severity was measured on the study casts of the EarlyTx and LateTx groups., Results: Successful Class II correction was observed in approximately three quarters of both the EarlyTx group and the LateTx group at the end of treatment. EarlyTx patients had fewer permanent teeth extracted than did the LateTx patients (5.6% vs 37.9%, P < .001) and spent less time in full-bonded appliance therapy in the permanent dentition than did LateTx patients (1.7 ± 0.8 vs 2.6 ± 0.7years, P < .001). When supervision time is included, the EarlyTx group had longer total treatment time and averaged more visits than did the LateTx group (53.1 ± 18. 8 vs 33.7 ± 8.3, P < .0001). Fifty-five percent of the LateTx extraction cases involved removal of the maxillary first premolars only and were finished in a Class II molar relationship., Conclusion: EarlyTx comprehensive mixed-dentition treatment was an effective modality for early correction of Class II malocclusions.

Objective: To investigate posttreatment changes in the maxillary and mandibular arches in patients who underwent orthodontic treatment during the mixed and permanent dentitions., Materials and Methods: The sample was collected retrospectively from three private practices and consisted of 42 patients who were at least 10 years out of orthodontic treatment. The longitudinal records of study casts and cephalometric radiographs were analyzed to quantify posttreatment changes., Results: Minimal changes in maxillary and mandibular irregularity occurred after an average of 16.98 years from completion of treatment. More than 10 years posttreatment, approximately 81% of the maxillary anterior teeth and 88% of the mandibular anterior teeth showed clinically acceptable incisor alignment (<3.5 mm). Mandibular fixed retainers greatly aided in maintaining the stability of the mandibular incisor alignment. However, posttreatment changes in maxillary incisor irregularity did not appear to be influenced by the presence of a mandibular fixed retainer. When compared with longitudinal changes observed in untreated subjects, the increase in incisor irregularity resembled a pattern similar to the regression line of untreated subjects and seems to be entirely age related. Arch width and arch depth was consistently decreased after treatment, but the magnitude of change was minimal at about 1 mm. No associations were found between any of the cephalometric measurements and changes in incisor irregularities., Conclusions: Orthodontic treatment stability can be achieved and mandibular fixed retention appears to be a valuable contributor, especially in patients with further growth expected.

Gender differences in cooperative choices and their neural correlates were investigated in a situation where reputation represented a crucial issue. Males and females were involved in an economic exchange (trust game) where economic and reputational payoffs had to be balanced in order to increase personal welfare. At the behavioral level, females showed a stronger reaction to negative reputation judgments that led to higher cooperation than males, measured by back transfers in the game. The neuroanatomical counterpart of this gender difference was found within the reward network (engaged in producing expectations of positive results) and reputation-related brain networks, such as the self-control network (engaged in strategically resisting the temptation to defect) and the mentalizing network (engaged in thinking about how one is viewed by others), in which the dorsolateral prefrontal cortex (DLPFC) and the medial (M)PFC respectively play a crucial role. Furthermore, both DLPFC and MPFC activity correlated with the amount of back transfer, as well as with the personality dimensions assessed with the Big-Five Questionnaire (BFQ-2). Males, according to their greater DLPFC recruitment and their higher level of the BFQ-2 subscale of Dominance, were more focused on implementing a profit-maximizing strategy, pursuing this target irrespectively of others' judgments. On the contrary, females, according to their greater MPFC activity and their lower level of Dominance, were more focused on the reputation per se and not on the strategic component of reputation building. These findings shed light on the sexual dimorphism related to cooperative behavior and its neural correlates.

The Piedmont Group of Clinical Nephrology compared the activity of 18 nephrology centers in Piedmont and Aosta Valley as regards acute pielonephritis (APN). Data from more than 500 cases per year of APN were examined. The microbial spectrum of APN consists mainly of Escherichia coli and Klebsiella pneumoniae. Diagnosis was based on both clinical and radiological criteria in most of the centers (computed tomography-CT o Magnetic Resonance Imaging-MRI). In four centers diagnosis was made with the radiological criteria and in one center only with the clinical features. CT and MRI were performed in about 47% and 44% of cases respectively. Urine culture was positive in 22 up to 100% of cases. The most commonly used antibiotics were fluoroquinolones (ciprofloxacin or levofloxacin) and ceftriaxone (50% of centers) or amoxicillin/clavulanic acid (25% of centers). In 75% of the centers, patients received a combination of two antibiotics (aminoglycoside in 22% of them ). In 72% of the centers, almost 50% of the patients were re-examined, while 38.8% of centers re-examined all the patients. Renal ultrasound was inappropriate to identify abscesses. The mean of patients in whom renal abscesses were detected by CT or MRI was 18.2%. The analysis shows a high variability in the way of diagnosing and treating APN in Piedmont and Aosta Valley regions. This suggests that even if APN is a frequent pathological condition, practical recommendations are required.

Introduction: The aim of the study was to assess the age-specific, sex-specific, and region-specific average sodium and potassium intake and its association with anthropometric characteristics in a sample of the Italian adult hypertensive population., Methods: A total of 1232 hypertensive patients were recruited consecutively by 47 centers recognized by the Italian Society of Hypertension. The enrolled participants were on stable antihypertensive treatment. Anthropometric indices, blood pressure, 24-h urinary sodium, and potassium excretion were measured and used as proxy for the average daily sodium and potassium intake., Results: The average sodium intake was 172  mmol (or 10.1  g of salt/day) among men and 138 (or 8.1) among women, with no difference among geographical areas. Over 90% of men and 81% of women had a consumption higher than the recommended standard dietary intake of 5  g/day. The average potassium intake was 63 and 56  mmol, respectively in men and women, again without geographical differences, nearly 92% of men and 95% of women having an intake lower than the recommended intake (100  mmol/day or 3.9  g/day). There was a significant trend to a gradual decrease in sodium intake with age in both sexes (P <0.001). There was also a direct association between BMI and sodium intake in both sexes, this association being independent of age (P < 0.001)., Conclusion: In this national sample of the Italian hypertensive population, dietary sodium intake was largely higher and potassium intake much lower than the recommended intakes, and this was true for all geographical areas. Overweight and obese hypertensive patients had particularly high sodium intakes.

The number of immigrants has been rapidly increasing in Italy in the last decade, with potentially profound effects on the national health care system. Yet, few data are available on the clinical and demographic features of these subjects, or on their need for nephrological care and dialysis treatment. A survey was conducted in 19 dialysis facilities of Piedmont (a northwestern Italian region) about immigrants on chronic dialysis treatment. Data on native country, administrative position, clinical and dialysis aspects were anonymously collected. Overall, 93 immigrant dialysis patients coming from 24 foreign countries were registered. Most of them were young (mean age 46∓14 years) and on extracorporeal treatment (87%); late referral (38%) or starting dialysis in emergency (17%) were common modalities of presentation. Glomerular (33%) or unknown (31%) nephropathies were the most representative causes of end stage renal disease. No difference in incidence of HCV, HBV and HIV compared with native Italian patients was observed. Notably, more than 50% of the immigrant patients had low-level knowledge of Italian. As regards administrative position, 69% were regular foreign citizens, 19% were temporary foreign workers, and 9% had a residence permit. Our survey confirms the existence of a young immigrant population on dialysis in Piedmont, whose social and relational problems are more challenging than clinical aspects and call for new organizational models to manage this growing population on dialysis.

Recent studies questioned the existence of a specific renoprotective effects of ACE-inhibitors (ACE-i) and angiotensin receptor blockers (ARBs) besides their blood pressure lowering effect. In the ALLHAT study patients were randomly assigned to receive chlorthalidone, amlodipine and lisinopril. Results showed that, even in patients with reduced GFR, neither lisinopril nor amlodipine was superior to chlorthalidone in reducing the rate of development of ESRD or a 50% or greater decrement in GFR. Because of inclusion criteria the ALLHAT population was selected as at low risk for renal outcomes. Moreover, over 50% of the patients who were randomized to lisinopril either never received the medication or received the lower possible dose. Casas et al selected RCT comparing ACE-i and ARBs with other regimens. They concluded that ACE-i and ARBs are not more renoprotective that can be explained by lowering of blood pressure (BP) in diabetic nephropathy, while in non diabetic kidney disease a blood pressure independent renoprotective effect is uncertain. They made a very heterogeneous selection of trials that was dominated by the ALLHAT study; the analysis was not based on individual patient data. The Benedict Study showed that in hypertensive, normoalbuminuric patients with type 2 diabetes, BP reduction and ACE-i therapy both independently may prevent microalbuminuria. ACE-i therapy is particularly effective when BP is poorly controlled. We conclude that the recommendation of the Guidelines to use ACE-i and/or ARBs as first-line antihypertensive drugs for renoprotection in patients with diabetic and non diabetic kidney disease is still valid.

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.

Background: We tested whether the combination of verapamil (V) or amlodipine (A) with trandolapril (T) affected proteinuria differently from T alone in patients with nondiabetic nephropathies., Methods: After T, 2 mg, in open conditions for 1 month, 69 patients were randomly assigned to be administered T, 2 mg, combined with V, 180 mg, plus a placebo or T, 2 mg, plus A, 5 mg, once a day in a double-blind fashion. Patients were followed up for 8 months., Results: Proteinuria diminished significantly after T treatment from mean protein excretion of 3,078 +/- 244 (SEM) to 2,537 +/- 204 mg/24 h (P = 0.018). In the randomized phase, there was a slight reduction in proteinuria in both groups without significant differences within and between treatments (T + V, protein from 2,335 +/- 233 to 2,124 +/- 247 mg/24 h; T + A, protein from 2,715 +/- 325 to 2,671 +/- 469 mg/24 h). The selectivity index (SI; calculated as the ratio of immunoglobulin G to albumin clearance) was slightly and not significantly reduced in patients treated with T plus V from a median of 0.20 (interquartile range, 0.13) to 0.16 (interquartile range, 0.15; P = not significant), whereas it significantly increased from 0.20 (interquartile range, 0.14) to 0.30 (interquartile range, 0.14; P = 0.0001) in patients treated with T plus A. Modifications in SI and serum creatinine levels at the end of the study from randomization were significantly directly correlated (r = 0.45; P = 0.001). The number of patients reporting adverse effects was significantly higher in the T plus A than T plus V group (63.8% versus 33.3%; P = 0.016)., Conclusion: In patients with nondiabetic proteinuric nephropathies treated with T, the combination of V or A does not significantly increase its antiproteinuric effect.

Acute pyelonephritis (APN) is a frequent disease, but diagnostic approach, evolution into abscesses, and indication to hospitalization are still open problems. We have made a retrospective analysis of APN cases observed in our hospital. We identified 58 patients (pt) and selected 52 of these who presented fever and loin pain at the onset (31 were hospitalized in Nephrology and 21 in other units). Urine culture was positive in 11/48 cases (22.9%), blood cultures in 3/26 cases (11.5%) (Escherichia coli). Renal sonography was normal in 20/48 cases (41.6%) and suggestive for APN in 23/48 cases (47.9%). CT with contrast medium was normal in 9/28 cases (32.1%) and positive in 19/28 cases (67.8%), with evidence of unique or multiple hypodense areas; abscesses were found in 8 patients (28.5%). No statistically significant differences were found between patients with positive or negative CT as regards fever, leukocytosis, ESR, CRP, CRP at 20 days, urinary leukocytes, urine culture, duration of symptoms before hospitalization. Moreover no differences were found between patients with and without abscesses. CT was performed more frequently among patients hospitalized in Nephrology than among patients hospitalized in other services (24/31-77.4%-vs. 4/21-19%-, p = 0.05). NMR was abnormal in 6/9 cases. A radiographic documentation of APN was obtained in 61.53% of patients with clinical diagnosis of APN. Of these, only 18.7% had positive urine culture. In conclusion, our data suggest that demonstration of urine infection is not necessary for APN diagnosis, when clinical and/or radiologic diagnosis of APN has been made. Evolution into abscesses is frequent and not easily susceptible on clinical ground; for this reason we think it is advisable to perform CT or NMR systematically. Differences in clinical behavior between different units suggest the need for diagnostic guidelines.

Background: The effectiveness of percutaneous revascularisation (PTRA) in the treatment of atherosclerothic renovascular nephropathy (ARN), a leading cause of progressive renal failure, is still a matter of debate., Methods: we reviewed 52 patients submitted to selective stenting from 1991 to 2000 because of ARN, followed for a mean of 22.3 months before and 24.6 after the procedure, looking for complications, re-stenosis rates, blood pressure, renal function and survival., Results: Arterial patency was achieved in 97.1% of procedures (71.6% by stent deployment); complications occurred in 42% of patients, and re-stenoses in 17.3% of vessels, most often in those without a stent (31.6% vs 8.3%). No effect was detectable on hypertension and renal failure in the whole group, but in the subgroup without technical failure or early dialysis start PTRA reduced the creatinine clearance (BCRC) decline from 0.9 to 0.19 mL/min/month. At univariate analysis, BCRC outcome was better in bilateral or single kidney stenoses, proteinuria < 1 g/day, serum creatinine < 4 mg/dL and resistance index < 0.8. Survival was 68.9% at five years, with a mortality rate of 4.5/100 person-years., Conclusions: Renal outcome of successful PTRA differs from case to case, but efficacy is substantial. Primary stenting in ostial stenosis and selection of patients based on prognostic factors seem likely to improve the effectiveness.

Background: Aim of this study is to evaluate the treatment and control of arterial hypertension in patients with type 2 diabetes., Methods: We identified 5815 diabetic patients in our health-care district (191,568 inhabitants) through prescriptions for insulin and/or hypoglycaemic drugs in the first 6 months of 2000; 3810 of them (65%) also had prescriptions for antihypertensive drugs. We evaluated a randomly selected sample of 171 patients with type 2 diabetes, 100 of whom were receiving antihypertensive drugs (94 males and 77 females, mean age 66.6 +/- 8 years, mean diabetes duration 12+/-9 years)., Results: Fifty-seven out of 71 patients not treated with antihypertensive drugs (80.3%) had a BP = 130/85 mmHg; 24.4% of them had a diastolic BP = 85 mmHg and 79% had a systolic BP = 130 mmHg. Thirteen out of 100 treated patients (13%) had a BP < 130/85 mmHg. Among the patients treated with antihypertensive drugs 36% received one drug, 36% two drugs and 28%=3 drugs; mean 1.98 +/- 0.9 drugs/patients. Among the patients treated with monotherapy 36.1% received ACE-inhibitors, 36.1% dihydropyridinic calcium-antagonists, 11.1% alpha-blockers, 11%, diuretics, 2.8% non-dihydropyridinic calcium-antagonists, and 2.8% angiotensin II antagonists. Patients treated with two antihypertensive drugs received more frequently an ACE-inhibitor plus a diuretic (31%) or an ACE-inhibitor plus an alpha-blocker (23%) or an ACE-inhibitor plus a dihydropyridinic calcium-antagonists (20%). A diuretic was used in 40% of the patients with two antihypertensive drugs and in 78% of those with >= 3 drugs., Conclusions: Many hypertensive type 2 diabetic patients are left untreated and only a minority of those treated reach optimal blood pressure control. The importance of an elevated systolic pressure is underestimated, and the number of antihypertensive drugs prescribed is suboptimal.

We have reviewed the role of salt intake in kidney diseases, particularly in relation to renal hemodynamics, renal excretion of proteins, renal morphological changes and progression of chronic renal failure. High salt intake may have detrimental effects on glomerular hemodynamics, inducing hyperfiltration and increasing the filtration fraction and glomerular pressure. This may be particularly important in elderly, obese, diabetic or black patients, who have a high prevalence of salt-sensitivity. Changes in salt intake may influence urinary excretion of proteins in patients with essential hypertension, or diabetic and non diabetic nephropathies. Moreover, high sodium intake may blunt the antiproteinuric effect of various drugs, including angiotensin-converting-enzyme inhibitors and calcium antagonists. Experimental studies show a direct tissue effect of salt on the kidney, independent of its ability to increase blood pressure, inducing hypertrophy, fibrosis and a decrease in glomerular basement membrane anionic sites. However, no firm conclusion can be drawn about the relationship between salt consumption and progression of chronic renal failure, because most information comes from conflicting, small, retrospective, observational studies. In conclusion, it would appear that restriction of sodium intake is an important preventive and therapeutic measure in patients with chronic renal diseases of various origin, or at risk of renal damage, such as hypertensive or diabetic patients.

Background: Aim of this study was a retrospective analysis of the renal biopsies performed in our Division., Methods: Since January 1, 1996 to September 30, 1999 289 biopsies were performed on native kidneys, 90 patients were older than 65., Results: The most frequent nephropathy was IgA glomerulonephritis (IgAGN) (28%), followed by membranous glomerulonephritis (MGN) (11%). In patients older than 65, the most frequent was MGN (20%), followed by IgAGN (12.2%). The total complications were 84 (29.1%) (hematomas >3 cm 1%; blood transfusion: 1.4%). Complications were not related to age, blood pressure, renal function, clinical presentation, number of shots. In 217 patients, the results obtained with two different modalities were compared: manual system (needle size=15 gauge) and automatic system (18 gauge). No statistically significant differences were found as regards the number of shots for single biopsy, number of glomeruli and major complications (1.6% vs 1.3%), while minor complications were more frequent in the second group., Conclusions: In conclusion, the number of renal biopsies performed in our Division has been increasing year after year. This trend can be partially explained by our wider indications to renal biopsy in elderly population (the data related to resident population showed the greatest prevalence of biopsies in patients 70 to 79 years old). Renal biopsy actually represents a safe examination even in elderly patients. From a technical point of view, on the basis of personal experience, 18 gauge acecut automatic needles seem to be preferred to other kind of devices.

Angiotensin converting enzyme inhibitors (ACEI) are the most effective antiproteinuric agents and should be used as first-line drugs in both diabetic and non-diabetic proteinuric nephropathies. The role of calcium channel blockers (CCB) is much more controversial. In diabetic patients verapamil and diltiazem seem more effective than dihydropyridines in reducing urinary protein excretion, and have additive effects with ACEI, but little is available on chronic treatment of non-diabetic nephropathies for non-dihydropyridine CCBs. To test whether the combination of verapamil 180 mg or amlodipine 5 mg with trandolapril 2 mg reduces urinary protein excretion more than trandolapril 2 mg alone, we planned a prospective, randomized, double-blind, multicenter trial. The secondary aims are to evaluate the effects of both treatments on the selectivity of proteinuria and check their safety. Consecutive patients aged between 18 and 70 years with non-diabetic proteinuria > or =2 g/24 h and plasma creatinine < 3 mg/dl or creatinine clearance > or = 20 ml/min are asked to participate. After a four-week run-in during which previous antihypertensive therapy is withdrawn, a single dose of trandolapril 2 mg is given once a day in open conditions for four weeks. At the end of this period patients are randomly assigned to receive once a day, in a double blind fashion, either trandolapril 2 mg and verapamil 180 mg [plus a placebo], or trandolapril 2 mg plus amlodipine 5 mg. They are monitored after one, two, five and eight months.

Background: To describe the clinical aspects of renal failure due to cholesterol atheroembolism., Methods: An hospital based observational study on renal failure due to cholesterol atheroembolism was carried out. Twenty-two cases (19 males, mean age 68 yrs, range 53-83 yrs) were identified from January 1992 to September 1998., Results: Clinical symptoms were acute or rapidly progressive renal failure with blue toe and/or skin livedo reticularis in 13/22 cases (59%) and indolent progressive renal failure in 7/22 cases (32%). In 6/22 cases (27%) an abdominal organ involvement was evident; two (9%) had retinal cholesterol emboli, two (9%) peripheral and two (9%) central nervous system impairment. In 7 patients (32%) the cholesterol atheroembolism occurred spontaneously, while in 15 (68%) it followed invasive or interventional radiology (8 cases, 36%); cardiac or vascular surgery (4 cases, 18%); thrombolytic or anticoagulant therapy (3 cases, 14%). The time interval between the procedure at risk and the onset of symptoms or signs of cholesterol atheroembolism ranged between few hours to 60 days. Eleven patients (50%) required dialysis, which was then withheld in 4 cases (36%), owing to partial functional recovery after a median time of 30 days, ranging from 10 to 690 days. Median follow-up was 2.5 months (ranging from 2 days to 68 months), and eleven patients (50%) deceased., Conclusions: Cholesterol atheroembolism is a cause of renal failure associated with high mortality rates; its prevention needs the skill of all physicians involved in the care of patients with severe atherosclerosis.

Background: To evaluate the metabolic effects of modification of sodium intake in patients with essential hypertension., Methods: Thirteen patients with essential hypertension (10 M, median age 51 yrs, range 21-64) followed in random order a low-sodium and a high-sodium diet (50 mmol Na/day vs 250 mmol/day for two weeks each). At the end of each diet an evaluation was made of 24 hour blood pressure (ABPM, Spacelabs 90207) and serum concentration of: glucose, total and HDL cholesterol, uric acid, lipoproteins A, B, Lp(a), total proteins, albumin., Results: Twenty-four hours systolic and diastolic BP were significantly higher at the end of high sodium diet than of low sodium diet [respectively 132 mmHg (120-161) vs 128 mmHg (109-150); p = 0.008 and 84 mmHg (71-99) vs 81 mmHg (70-95); p = 0.008)]. No significant variations were found as regards serum glucose and lipidic parameters between low and high sodium diets. Serum uric acid was significantly higher following low sodium diet [5.9 mg/dl (4.5-8) vs 4.6 mg/dl (3.4-6.5); p = 0.003)], as well as serum total proteins [7.2 g/dl (6.9-8.2) vs 7 g/dl (6.5-7.8); p = 0.027)]. A significant direct correlation was found between changes of uric acid and total proteins from low to high sodium diet (Spearman's rho = 0.57; p = 0.04)., Conclusions: In patients with essential hypertension a moderate dietary sodium restriction, able to reduce significantly 24 hours arterial pressure, does not worsen serum glucose nor lipids concentration.

Ischemic nephropathy refers to the kidney damage following stenosis or an obstructive lesion in the main kidney arteries. This disorder has been overlooked in the past and a more rational and specific use of clinical criteria, and the development of not very invasive techniques with a good diagnostic accuracy such as spiral CT angiography, NMR angiography and echo-colour-Doppler have improved our ability to identify these patients. It is therefore likely that, in the next few years, we will find ourselves treating an increasing number of patients with renovascular ischemic disorders. Transluminal angioplasty and, more recently, the use of endovascular stents, have led to a marked improvement in the treatment of stenoses and, together with vascular surgery, allow to treat almost all patients with this disorder. There is, however, a lack of prospective and controlled studies, which demonstrate the long term benefit of revascularization treatment, as compared with optimum conservative treatment in reducing cardiovascular mortality, cardiovascular events and preserving renal function. The Ischemic Nephropathy Study Group of the Italian Society of Nephrology has organized a prospective, controlled study over a period of three years, aimed at comparing the effect of revascularization versus medical therapy in 300 patients with renal artery stenosis, ranging between 50 and 90 per cent, who will be randomly assigned to the two treatments. End point will be cardiovascular mortality and morbidity and need for renal replacement therapy.

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.

This lateral cephalometric study investigated the dental and skeletal effects of the Jasper Jumper appliance used in the correction of Class II Division 1 malocclusions. A sample of 36 growing patients treated with the Jasper Jumper appliance was divided into two groups: (1) 24 patients with records obtained at the start and completion of orthodontic treatment, and (2) 12 patients with records available at the beginning and end of the Jumper phase of treatment. Treatment effects were determined by statistical comparisons of cephalometric changes in the patients relative to age-adjusted cephalometric standards, and from structural superimpositions. While the Jumpers were in place, maxillary incisors were retroclined and the molars were moved distally, tipped back, and intruded. The mandibular incisors were proclined and intruded, while the molars were translated mesially, tipped forward, and extruded. Skeletal measures showed reduced forward maxillary displacement and no significant alteration of horizontal mandibular growth. During orthodontic finishing, molar tipping and maxillary incisor retroclination were corrected, although the mandibular incisors remained proclined. In summary, this study found that the Jasper Jumper appliance corrected Class II discrepancies largely through maxillary and mandibular dentoalveolar effects and, to a limited extent, by restraint of forward maxillary growth.

OBJECTIVES: To evaluate the prevalence of hypertension, the average blood pressure level, the 24 h blood pressure profile, and the efficacy of antihypertensive therapy for a large population of peritoneal dialysis patients.DESIGN: A cross-sectional, observational multicenter study. METHODS: From 504 peritoneal dialysis patients (18% of the Italian peritoneal dialysis population) involved in a multicenter observational study, we selected 414 who had undergone successful ambulatory blood pressure monitoring (i.e. no hours with data absent, >/= 75% successful readings and monitoring duration >/= 24 h). Office blood pressure measurements and ambulatory blood pressure monitoring were performed for each patient on the same day with a standard mercury sphygmomanometer and a SpaceLabs 90207 device, respectively.RESULTS: According to World Health Organization/International Society of Hypertension criteria, 44 peritoneal dialysis patients (10.6%) were normotensive and 370 patients (89.4%) were hypertensive, 304 (82.1%) of whom were being administered antihypertensive therapy. Daytime systolic and diastolic blood pressures were both significantly lower than office systolic and diastolic blood pressures (140.7 +/- 19.7/72.1 +/-11.1 versus 148.3 +/- 23.6/85.6 +/- 12 mmHg; P < 0.001). The difference between office blood pressure and daytime blood pressure was significantly correlated to office blood pressure (P < 0.001 for systolic and P < 0.001 for diastolic). The diurnal blood pressure rhythm evaluated by visual inspection of hourly mean plots was not influenced by sex, age, antihypertensive treatment, and peritoneal dialysis modality. Systolic and diastolic blood pressures exhibited a day-night mean decreases of 8.6 +/- 11.7 and 7.7 +/- 6.9 mmHg, respectively, and daytime blood pressure values were significantly higher than night-time ones (P < 0.001). Two hundred and twenty patients (53.1%) were nondippers according to O'Brien's criteria, 247 patients (59.7%) were nondippers according to Verdecchia's criteria, and 269 patients (65.0%) were nondippers according to Staessen's criteria. Only 39 patients (9.4%) had a reversed circadian rhythm. The day-night differences of systolic and diastolic blood pressures were in a unimodal distribution. Among hypertensive patients not being administered antihypertensive therapy, only six patients ( five women and one man) had white-coat hypertension. Among hypertensive patients being administered antihypertensive therapy, 235 patients (77.3%) had 24 h blood pressure loads > 30%.CONCLUSION: There is a high prevalence of hypertension among peritoneal dialysis patients. White-coat hypertension is very rare in this population. Despite the extensive use of antihypertensive therapy, control of blood pressure is maintained in a large number of our peritoneal dialysis patients. Any classification of patients into dipers and nondippers must be interpreted cautiously.

Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.

Following orthodontic treatment, an increase in the number of occlusal contacts is usually desired during retention. In this study, Hawley and clear overlay orthodontic retainers were compared relative to changes in the number of occlusal contacts. Occlusal contacts were quantified in 30 orthodontic patients at debonding, at retainer delivery, and after 3 months of retention. The paired t-test was applied to evaluate longitudinal changes in the number of and intensity of contacts. Results show that with the Hawley retainer there was a significant increase in occlusal contacts on posterior teeth and no change on anterior teeth. With the clear overlay retainer there was no significant change in either posterior or anterior contacts during retention. The retentive capacities of the two retainers differ: the Hawley retainer allows relative vertical movement (settling) of the posterior teeth while the clear overlay retainer holds teeth in their debanding position.

A case of splenic large B-cell lymphoma with hemophagocytic syndrome is reported. The difficulties of diagnosis are emphasized especially when peripheral lymph nodes or bone marrow lymphomatous infiltration are not present. Diagnostic criteria for hemophagocytic syndrome and their relationship with the pathogenesis of the disease are also stressed.