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This study aimed to evaluate the anti-proteinuric effect of a very-low-protein diet supplemented with essential amino acids and keto analogs in patients with moderate to advanced chronic kidney disease and proteinuria already treated with both ACE inhibitors and angiotensin-receptor blockers. The study was a prospective randomized controlled cross-over trial comparing a very-low-protein diet (VLpD) and a low-protein diet (LpD). We enrolled 32 consecutive patients between June 2000 and June 2005. They were randomized to receive a VpLD (group A) or an LpD (group B) for 6 months; thereafter, patients of both groups were switched to the other diet (group A to LpD; group B to VpLD) for a further 6 months. Finally, all patients were randomized again within each group to receive either LpD or VLpD and were followed for another year. The VLpD group showed a significant reduction of urinary protein excretion during the diet period, with a nadir at the fourth month of treatment; the amount of urinary protein reduction was about 58%. Serum advanced glycation end products (AGE) significantly decreased in 10 patients (5 of group A, 5 of group B; -18% and -19%, respectively) during VLpD. Univariate analysis showed that proteinuria correlated indirectly with VpLD and directly with AGE. This study demonstrates that in patients with moderate to advanced chronic kidney disease and severe proteinuria, a VLpD reduces both proteinuria and serum AGE, even in the presence of complete inhibition of the renin-angiotensin system.

The ideal dialysis access ensures adequate blood flow for dialysis, has a long life, and is associated with a low complication rate. Although no current type of access fulfills all these criteria, the native arteriovenous fistula (AVF) is close to doing so. Unfortunately, various kinds of vascular access (VA) are becoming more and more necessary to enable hemodialysis (HD). The central venous catheter (CVC), which is associated with higher morbidity and mortality, could be the only viable option to maintain permanent VA. We report an unusual complication in a patient, a 74-year-old female, who had been undergoing HD via a CVC for 14 yrs. A polyurethane CVC with a double lumen was inserted into the right internal jugular vein because an AVF was not feasible, and a polytetrafluoroethylene (PTFE) prosthesis was obstructed. In 2003, the CVC was removed due to stenosis and occlusion of the superior vena cava. A new CVC, also made of polyurethane and with a double lumen, was inserted into the left femoral vein. In January 2005, the patient reported a small rupture of about 3-4 mm located under the cuff of the CVC. For this reason, the left femoral vein had to be used, replacing the Optiflow one with a 40-cm long Tesio CVC, and the second catheter was inserted into the right femoral artery by conventional surgery. After 10 months, the patient returned once more, after the CVC in the left femoral vein had been removed because of malfunction and that the at-tempts to cannulate the same vein again had failed. Currently, two 70-cm long Tesio catheters implanted in the right femoral vein (whose tips almost reach the diaphragm) are used for dialysis sessions. The number of CVC implants has progressively increased amongst HD patients who are elderly, diabetic or who have been on long-term HD. The patient described in this case report is currently using a 70-cm long double Tesio catheter (single Tesio CVC in SPI silicon) placed in the right femoral vein. She has resumed therapy with dicumarol anticoagulants, maintaining INR within the 2.5-3.5 range. In conclusion, both the increase in the use of venous catheters for HD and in the survival of dialysis patients contribute towards the observation of rare complications associated with CVC use.

Bioelectrical analysis (BIA) is an easy, repeatable, low cost, operator-independent method. BIA obtains two different goals, i.e. body water content evaluation, by the RXc Graph or the BIVA Z score and morbidity and mortality predictions by the phase angle. Therefore, BIA can be considered as part of the clinical examination for the evaluation of both hydration and nutritional status.

Early referral to nephrologists of patients with chronic renal failure (CRF) reduces morbidity and mortality in dialysis. Aim of this work is to evaluate the condition of early and late referral, and whether the two different conditions can affect the treatments.This is a prospective study with a 12-month follow-up period. During this time, we verified the prevalence of patients with serum creatinine1.5 mg/dL (CRF patients) and the condition of early or late referral, defined as referral to nephrologists foror3 times during follow up, respectively. Diagnosis of diabetes mellitus and/or arterial hypertension, and the use of antihypertensive drugs, insulin, hypoproteic diet and erythropoietin was recorded in each patient.CRF (mean serum creatinine value = 2.11+/-1.52 mg/dL) was observed in 190 patients aged 72.05+/-11.62 years. The prevalence of CRF was 4718 pmp. Diabetes and hypertension were diagnosed in 107 subjects (56.3%) and 152 subjects (80%), respectively. Only 74.2% (no. 141) of the patients with CRF was habitually followed by the nephrologist and the frequency was directly correlated to the degree of CRF: 100% of the patients with Creatinine Clearance (Cr Cl)25 mL/min, 70% with Cr Cl2550, and 0% with Cr Cl5080 mL/min. Early referral was coupled with a wider use of a hypoproteic diet, erythropietin, and the association ACE-I + Angiotensin II receptor antagonists.In conclusion, our data show a prevalence of CRF that is at least 5 times greater than that of dialysis patients. The condition of late referral is present in about 30% of the CRF population from the time of the initial phases of renal disease. Referral time affects the modalities of the treatment.

The incidence of thalassaemia minor in end-stage renal disease patients is similar to that of the general population. Both these conditions are characterized by anaemia, but the underlying pathophysiology is quite different. Current literature lacks an adequate clinical survey of haemodialysis patients with thalassaemia minor.The prevalence of thalassaemia minor (thal-m) in haemodialysis patients was assessed by a national survey collecting general information as well as clinical and haematological parameters. Data were also collected on the use of recombinant erythropoietin in these subjects. A dedicated questionnaire was sent to all Italian dialysis units.Only 116/705 dialysis units returned the questionnaire (16.4%): 33 units did not have any patients affected by thalassaemia minor. No response was obtained from six Italian regions whereas ten regions returned only partial answers. The response from four regions was satisfactory (20%) while the completed questionnaire was returned by all units in only two small regions. A total of 7731 ESRD patients were collected, 240 (3.1%) were also affected by thal-m, 142 males and 98 females. In the four regions with the highest response rates, Calabria 45%, Puglia 65%, Basilicata and Molise 100%, the prevalence of thal-m were 3.68%, 4.56%, 3.3% and 1%, respectively. A total of 3623 uraemic patients (47% of all enrolled subjects) were collected from these four regions. Here is the patient geographic distribution: northern Italy 2.16% (response rate of 9.44%); central Italy 1.69% (response rate of 7.64%), southern Italy 3.77% (response rate of 29.46%). The age range of thal-m patients was 17 to 90 years, the time spent on dialysis was between 3 and 384 months, the body weight was between 35 and 93 kg, the Hb value was between 6.2 and 13.6 g/dl, and the Htc value was between 19 and 44%. A total of 230 thal-m patients were on haemodialysis while 10 patients were on peritoneal dialysis (4.2%). The mean haemoglobin level for the thal-m group was 9.8+/-1.4 g/dl and for the control group the value was 11.4+/-1.4 g/dl (p0.0001). The use of rhEPO was on the average 7659+/-6256 u/wk for the thal-m and 4378+/-4435 u/wk for the control group (p0.0001). The bodyweight was 129+/-105 u/kg/wk (range 0-370). Finally, 17.9% of the thal-m patient did not use rhEPO, their Hb value was 10.66+/-1.67 g/dl (range 8.2-13). No patient went over 30 thousand units and only 4 had such dosage in therapy. The 12.1% thal-m patients with Hb10 g/dl did not use rhEPO. The need for rhEPO per gram of Hb was 796+/-722 u/wk in thal-m patients and 416+/-449 U/wk in control patients (p0.0001). Uraemic anaemia was corrected with 4.8 million red blood cells in the control group and with about 7.7 million red blood cells in the thal-m group.Data from this national survey, although incomplete, show that rHuEpo is less effective in these patients and its use does not seems to be correct. It is important to emphasise that recent Guidelines do not recommend neither a specific treatment for these patients nor the use of r-HuEpo. However, it should also be underscored that most thal-m patients do not reach the target Hb level suggested by the National Guidelines for the general population in chronic dialysis.

Bioelectrical impedance analysis (BIA) allows simple noninvasive estimation of body water, and it could potentially be a very useful technique for clinical monitoring and study of abnormalities of body water. It has been shown that the total body impedance is dominated by the arm (46%) and leg (44%). The trunk, which represents an average of 46% of the body weight, accounts for only 10% of the total impedance. The objective of the current study was to determine the errors in prediction of body composition from BIA when applied to dialysis patients with measurement on the nondominant arm, postural changes, muscular contractions or cramps, monolateral lymphoedema, arteriovenous fistula, central venous catheter, or vascular graft. We studied 20 healthy subjects, 20 uremics on chronic hemodialysis, 3 uremics with fever (body temperature38.5 degrees C), 3 uremics with cramps, 3 patients with monolateral lymphoedema of an arm, and 3 patients with a prosthetic fistula on an arm. The results of our study show different values of total body water (TBW) derived by BIA measurements effected on supine or standing position (percentage rate variation = 1.1% to 1.6%), or effected during fever (6%), during cramps (-0.73%), with lymphoedema (25%), or in presence of a native arteriovenous fistula, a catheter in a central vein, or a graft (between -24% and +4%). We concluded that a significant error may occur in the measurement of body composition from whole body BIA when performed in the reported cases.