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Background and Aims Post transplantation anaemia (PTA) is a common finding in kidney transplant patients, with reported prevalence ranging from 25 to 40%, and it is associated with adverse outcomes for the kidney allograft and the recipient. The pathogenesis of PTA is multifactorial, including iron deficiency, reduced graft function, untoward effects of drugs (immunosuppressants, ACE-I and ARB), folic acid and vitamin B12 deficiency, inflammatory states. Ferric carboxymaltose (FCM) reportedly improved haemoglobin (Hb) levels and replenished depleted iron stores in various populations of patients with iron-deficiency anaemia, but there are few data about its use in PTA. In this study we evaluated the effectiveness and tolerability of high intravenous doses of FCM (500 mg) for the treatment of iron deficiency and anaemia in patients with kidney transplant. Method Absolute iron deficiency was considered as transferrin saturation (TSAT) less than 20% with ferritin levels below 100 µg/L. Anaemia was defined as Hb Out of 101 patients with kidney transplant, 56 presented with absolute iron deficiency (59±13 years old, M/F=0.95, 8±4.6 years of transplantation; serum creatinine 1.45±0.64 mg/dL): of these, 40 patients had anaemia (7 were also taking ESAs) and 16 had normal Hb levels. The 16 patients with absolute iron deficiency and normal Hb were not prescribed iron supplements, fearing of causing erythrocytosis, whereas 36 of 40 patients with anaemia and iron deficiency were given FCM 500 mg, as i.v. infusion for 30 minutes. Hb, ferritin and TSAT were assayed either before and 45-60 days after FCM supplementation, which was repeated if Hb levels were less than 0.5 g/dL below the normal value. Data were reported as mean±SD. Results Among the 56 patients with absolute iron deficiency, there were not any significant differences in serum levels of folic acid and vitamin B12 between those with and without anaemia (p=ns). After the first dose of FCM, in 36 patients with iron deficiency and anaemia, ferritin levels increased from 55±69 ng/mL to 111±107 ng/mL (p Out of the 17 patients still showing anaemia after the first FCM dose, 10 had Hb levels less than 0.5 g/dL below the normal value and were given a second dose of FCM. In this subset, Hb level increased on average from 11.4±0.5 g/dL to 12±0.9 g/dL (p After the FCM course, in 2 out of 7 patients ESAs were discontinued, whereas in 3 patients their doses were reduced and in 2 patients remained unchanged. Only one patient had an adverse effect during FCM infusion, namely, a transient skin flushing on her face during the second dose, which immediately remitted when the infusion was interrupted. Conclusion In patients with PTA and absolute iron deficiency, single or repeated doses of 500 mg of i.v. FCM were effective in improving Hb levels, well tolerated and reduced the need for ESAs. Of 56 patients with kidney transplant and absolute iron deficiency, 16 (28%) had normal Hb levels. We did not treat such subjects, fearing of causing erythrocytosis. However, given that iron deficiency may affect negatively both heart and muscle metabolism, what is the best management of iron deficiency in transplanted patients without anaemia is still an open question.

Background and Aims Autosomal dominant PKD determines formation of multiple cysts predominantly in the kidneys and usually becomes symptomatic during adulthood and can lead to renal failure. In contrast, in autosomal recessive PKD cysts occur in both the kidneys and the liver and usually presents an earlier onset. Obtaining genetic diagnosis is important to confirm clinical diagnosis and is required before treating with vasopressin 2 receptor blockers, which are the only drugs known to slow down the disease. Furthermore, in the case of kidney transplant from a living family member it is essential to exclude the presence of the mutation in the donor. We used clinical exome sequencing to provide genetic diagnosis to a cohort of patients with a clinical suspicion of PKD. Method 175 patients were referred to the Immunogenetics and Transplant Biology Service of the Turin University Hospital through a network of nephrology centers operating in the Piedmont region. Some patients were referred following genetic counseling. All patients signed an informed consent and the referring physicians provided relevant clinical data. DNA from eligible patients was extracted, checked for integrity, quantified and used for library preparation. A clinical exome sequencing (CES) kit by Illumina was used, allowing the analysis of 6,700 clinically relevant genes. Results Out of the 175 recruited patients eligible for CES, 38 (21.7%) had a clinical suspicion or diagnosis of PKD, with 50% of them presenting family history. The majority of the cohort was represented by male subjects (60.5%) and included both children (34.2%) and adults. The analytical approach was based on initial analysis of genes responsible for PKD (PKD1, PKD2 and PKHD1). If no mutation could be identified, analysis was then extended to a panel of 99 genes responsible for ciliopathies. This approach led to the identification of causative variants in 33/38 (86.8%) of the PKD cohort, while no variant could be identified in 5/38 patients. In 5/33 (15.2%) patients, mutations were inconclusive as found in heterozygosity in genes known to have an autosomal recessive mode of inheritance, while 27/33 (81.8%) were in line with the initial clinical suspicion/diagnosis. Of these, the majority was represented by missense mutations (12), followed by frameshift and nonsense mutations (6 each) and 3 splicing variants. As expected, the majority of mutations were found in PKD1 17/27 (63%), PKD2 3/27 (11.1%) and PKHD1 2/27 (7.4%). In these two latter patients, variants were found as compound heterozygosity. We also found mutations in other genes known to cause cysts, including TSC2 and CPT2. Of note, in 7 patients carrying PKD1 mutations, we found a second variant in PKD1 or PKHD1. Interestingly, when looking at patients characterized by kidney failure but lacking a clinical suspicion at recruitment or diagnosed with other phenotypes (66/175), we found variants in PKD1 and in PKD2 in 11 patients (9 and 2, respectively). Of all identified variants in PKD1, PKD2 and PKHD1 genes, 17.6% were annotated as pathogenic (C5), 41.2% were likely pathogenic (C4) and 41.2% were variants of unknown significance (C3). 19 variants in these genes were not previously reported. All the variants found in genes responsible for PKD were validated and confirmed by Sanger sequencing. Family segregation studies are ongoing. Finally, it is worth mentioning that in a portion of cases (5/38) with clinical and phenotypic features of PKD, supported also by a positive family history, we could not detect mutations in causative genes. These results may be explained by the presence of intronic variants, in line with data reported in literature. Conclusion These results demonstrate that CES may be applied to PKD patients to identify causative variants during their routine diagnostic flow. Furthermore, CES may be a useful tool to detect mutations in PKD-related genes in patients with undiagnosed diseases, considering its rapidly decreasing costs.

Many recent papers analyze the association between renal stone disease and other diseases that are typical of industrialized countries. Epidemiology studies from large series indicate that the prevalence of nephrolithiasis is higher among patients with metabolic syndrome, diabetes, and hypertension. Patients with nephrolithiasis also have an increased risk of myocardial infarction and stroke. It has been hypothesized that the common underlying defect could be insulin resistance. This, in turn, alters the urine biochemistry (i.e. more acidic pH and less urine citrate) thereby increasing the propensity of stone forming. In the diabetic rat renal steatosis has been implicated in the reduced production of ammonia, which has been shown to be reversible after PPARγ administration. Furthermore, pioglitazone was shown to be effective in reducing ethylene glycol-induced renal injury. Another significant association concerns gout. Two recent papers report that both calcium and uric acid stone disease are more prevalent among patients with gout. The metabolic derangements found in gouty and non-gouty patients were quite similar. CT imaging in patients with gout indicates that the incidence of nephrolithiasis is underestimated if only based on stone history. Finally, stone episodes may occur many years before the first gouty attack. Another interesting issue is that of a potential adverse effect of calcium and vitamin D supplementation on the risk of stone formation. It has been shown that treated post-menopausal women have a slight but significantly higher risk of forming stones, independently of other interfering variables. From this the recommendation to evaluate the actual benefit of supplementation, even more in the face of its ineffectiveness to prevent fractures in older women. Bariatric surgery is increasingly proposed for managing severe obesity, and in the last few years it has shown a widespread use in the US. Previous procedures of digestive diversion were often complicated by hyperoxaluria and renal oxalosis. More recent techniques, including Roux-en-Y gastric bypass and gastric bending, seem to give better outcomes. Hyperoxaluria and hypocitraturia following these procedures induce only minor increases in the risk of forming stones, but some recent reports of renal oxalosis after gastric bypass deserve attention.

Many recent papers analyze the association between renal stone disease and other diseases that are typical of industrialized countries. Epidemiology studies from large series indicate that the prevalence of nephrolithiasis is higher among patients with metabolic syndrome, diabetes, and hypertension. Patients with nephrolithiasis also have an increased risk of myocardial infarction and stroke. It has been hypothesized that the common underlying defect could be insulin resistance. This, in turn, alters the urine biochemistry (i.e. more acidic pH and less urine citrate) thereby increasing the propensity of stone forming. In the diabetic rat renal steatosis has been implicated in the reduced production of ammonia, which has been shown to be reversible after PPARγ administration. Furthermore, pioglitazone was shown to be effective in reducing ethylene glycol-induced renal injury.Another significant association concerns gout. Two recent papers report that both calcium and uric acid stone disease are more preval...

Primary hyperparathyroidism (PHPT) may favor nephrolithiasis mainly through an increase in calcium and phosphate urinary excretion. Cinacalcet exhibits good efficacy to control hypercalcemia in PHPT, but it is not so far known whether it might be a useful tool to prevent stone recurrences. Of 67 patients with PHPT and recurrent nephrolithiasis, 55 underwent parathyroidectomy (PTX) and 12, not eligible to PTX, were prescribed Cinacalcet. All the patients were evaluated for mineral metabolism, including estimation of state of saturation for calcium oxalate (CaOx) and brushite (bsh), both at baseline and after either PTX or Cinacalcet. PTX compared to baseline reduced PTH (4617 vs 15786 pg/mL, p0.01), calcemia (9.40.5 vs 11.30.9 mg/dL, p0.01), calciuria (3.62.3 vs 9.24.5 mmol/24h, p0.01), phosphaturia (18.47.1 vs 21.99.9 mmol/24h, p0.05), CaOx (4.73.9 vs 9.86.8, p0.01) and bsh (1.10.9 vs 3.22.2, p0.01). Cinacalcet decreased both PTH (13379 vs 17187 pg/mL, p0.05) and calcemia (9.70.6 vs 11.20.8 mg/dL, p0.001), whereas no change was seen in calciuria (7.42.2 vs 7.42.4 mmol/24h, p=ns), phosphaturia (21.97.3 vs 23.06.5 mmol/24h, p=ns), CaOx (6.92.7 vs 5.42.5, p=ns) and bsh (1.71.1 vs 1.31.3, p=ns). We conclude that in patients with PHPT, PTX is able to decrease the risk for crystallization of calcium salts, whereas calcimimetic Cinacalcet did not. Therefore, in patients with PHPT complicated with nephrolithiasis only PTX can improve urine biochemistries thereby reducing the risk for recurrent calcium stone disease.

Background: Unfractionated heparin (UFH) is the standard anticoagulant in regular dialysis treatments (RDTs), despite the fact that it may induce thrombocy- topenia, dyslipidemia, allergy and osteoporosis. Der- matan sulfate (DS) selectively inhibits thrombin, does not inhibit F-Xa and does not interfere with platelets (PLTS). Here we described an original protocol for the use of DS as anticoagulant in RDT and compared its effects with those of UFH. Methods: In 102 patients, 7,254 RDTs were performed using DS for anticoagulation (DS-phase) and 5,707 with UFH (UFH-phase). DS was supplied as initial bo- lus (80 ± 12 mg) and continuous infusion (14 ± 7 mg/ hour). With UFH, the initial bolus was 1,475 ± 141 IU and continuous infusion 576 ± 349 IU/hour. Activated par- tial thromboplastin time and its ratio were measured at least monthly, both before (pre-RDT APTT ratio) and af- ter (post-RDT APTT ratio) RDT sessions. With 41of 102 patients, both DS and UFH doses were not changed during study phases (stable patients). In this subset, the coefficient of variation (CV) of all pre-RDT APTT ratio and post-RDT APTT ratio values was calculated. Results: In DS and UFH phases, post-RDT APTT ra- tio increased by 61% and 50%, respectively, by com- parison with pre-RDT APTT ratio (p

BackgroundConsent to therapy is increasingly requested in the form of “informed consent”.ObjectiveTo validate an evidence-based informed consent form for erythropoietin (EPO) therapy and to evaluate patient opinions about the informed consent approach.MethodsAn evidence-based informed consent form was developed as part of the Evidence-Based-Medicine course at the Medical School of Turin, Italy. It was validated by anonymous questionnaires (0–10 analogical scales and open answers) administered to patients at different stages of CKD (19 pre-ESRD, 26 hemodialysis, 12 transplant patients) attending an outpatient unit of the University of Turin, to 8 nurses, and to 26 medical students.ResultsAll individuals filled in the questionnaire. Interest in a detailed explanation of the therapy was high (median 9), as was comprehension (median 9), with no differences between patients with regard to disease stage (pre-ESRD vs. RRT) or educational level. Prior knowledge of the therapy was affected by the educational level (p=0.013 for the advantages and p=0.004 for the side effects) and the professional role (patients vs caregivers: p=0.009 for the advantages and pConclusionsPatient interest in and comprehension of an informed consent form with a detailed explanation of the therapy was high; the caregiver's opinion was still the most valued teaching tool.

Non-compliance is crucial in chronic diseases and increases with complexity of therapies. Objective and methods: to build and validate, in a pilot study involving home and self-limited hemodialysis (HD) patients, a questionnaire assessing dialysis related discomfort (12 items, 4 fields: support therapies, time requirements, relationship with hospital-machine, dialysis related discomfort) and the advantages of flexible schedules and simplified therapies (6 items). A 0–10 visual analogue scale was employed. Results. The study was completed by 50/52 (96%) patients on home or self-limited care HD in a satellite Unit: median age 50 yrs (24–80), follow-up 40 mths (2–360); therapy: 10 pills/day (2–24), 2 subcutaneous injections/week (2–30). The highest scores, describing discomfort, were recorded for: time requirements (median score 8/10), dependence upon the machine (7/10), needle punctures (6/10), drug therapy, vascular access and dependence upon others (5/10). The option of flexible schedules and simplified support therapies obtained maximal scores (median 10/10). No relationship among single scores, clinical data, dialysis or support therapy was found. According to the pattern of the answers, patients were grouped into three main profiles (attitude towards dialysis related problems): stoic (20 cases), suffering (11) and selective (19). No correlation with clinical data and profile was found. Conclusion. Support therapies and organizational aspects cause important discomfort to our dialysis patients. Further studies in different cohorts are needed to define them, to optimize treatment acceptance and compliance.

One of the most feared problems in DHD is the risk of vascular access failure, so that it often limits the diffusion of this technique. Available data are limited; moreover, in most cases data regard home hemodialysis (HHD) patients, with the problem of the risk of a selection bias. The aim of the study was to evaluate the number of fistula complications (occlusion, infections, necessity of surgical treatment, angioplasty or urokinasi) in two groups of patients either on a DHD or on other dialysis schedules, in patients at home or in Limited Care Center. In the period considered (total period about 1500 patient-months; HHD: non DHD 463, DHD 278 months; Limited Care Center: non DHD 613, DHD 140 months) we registered 37 events (12 with vascular access occlusion, 11 with necessity of surgical treatment, 14 with necessity of other intervention, angioplasty or urokinasi). In particular, we registered 23 events in HHD (18 non DHD, 6 with vascular access occlusion and 5 DHD, 3 with vascular access occlusion, respectively 4/100 and 2/100 patient-months), 14 events in Limited Care Center (8 non DHD, none with vascular access failure and 6 DHD, 3 with vascular access failure, respectively 1/100 and 4/100 patient-months). Survival curves according to Kaplan-Meier didn’t show significant differences for DHD group; a worse survival was shown for HHD patients. In a Cox-proportional hazard model history of previous vascular episodes and HHD were independent risk factors (RR 2.01, 95% CI 1.06–3.83 and RR 1.98, 95% CI 1.15–3.39 respectively; overall score 0.04), while a protective role for male sex was present (RR 0.54, 95% CI 0.30–0.96). In conclusion: The increased number of punctures in DHD didn’t cause, in our study, an increase in the risk of vascular access occlusion. The surprise was the disadvantage of HHD compared to dialysis in Limited Care Center, contrary to all expectations. Results from this observational study will be study in depth (relationship with previous vascular problems, hypotension, body weight loss, biochemical risk factors, dialysis efficiency) and for a more prolonged period.

BackgroundDialysis is often neglected in academic teaching. At the University of Torino, Italy, teaching Nephrology (4thyear of Medical School) consists of 21 hours of formal lessons, 10 hours/student of interactive lessons (4/10 dedicated to dialysis) and 10 optional lessons (3 regarding dialysis). Interactive and optional lessons widely employ computer assisted teaching. Aim of the study was to evaluate student satisfaction on this approach.MethodsStudent satisfaction was assessed on 4 sample lessons (166 students), by two short dedicated questionnaires (0–10 scale, open questions).ResultsHigh scores were given to the dialysis lessons (median 8/10). Computer assisted interface (median 8/10, range 6–10) was of help in check of knowledge in real time (86%), enhancing participation (61%); 62% suggest extending this experience to selected courses, 38% to all.ConclusionsMedical students consider dialysis an important part of the academic teaching of Nephrology; new interfaces may help to enhance student satisfaction.

Background “Social risk behaviors” are usually considered as contraindications for organ donation. The organ shortage, however, necessitates expansion of the donor pool. Reconsideration of the policy toward substance abusers may be important. Opinions of the overall population may be of use to define this cultural-sensitive issue. Methods A semistructured questionnaire on organ donation, including opinions on drug use (cannabis and cocaine), was administered to various groups of the general public and caregivers: high school students (liceo classico: 59 students, median age 18 years; istituto tecnico: 108, age 17); first- and fourth-year medical school (77, age 19; 46, age 22); continuing medical education (44, age 32); third-year nursing school (31, age 23); “senior citizen university” (51, age 63). Results Cannabis use was mainly accepted for kidney donation (48.6% yes, 26.6% no, 29.8% uncertain/blank), but cocaine use was not (22.1% yes, 44.2% no, 33.7% uncertain/blank). In the univariate analysis, opinions differed according to age, sex, and belonging to the health care teams upon multivariate analysis being a member of the health care team was the strongest predictor of responses ( P Conclusion It is difficult to define social risk behaviors. Since opinions are important for organ donation, further studies and discussion are needed to periodically analyze our policies.

Despite the relatively little space for transplantation in most medical schools, this issue is considered interesting by the students both for its clinical and ethical implications. The students were asked to choose a particular aspect of nephrology for a 2-hour case discussion. They chose the case of a 35-year-old female, kidney transplant recipient now 1.5 years postoperatively, who was coming to seek advice about pregnancy. The aim of the present work is to report an integration between narrative and evidence-based medicine (EBM) approaches. The search strategy was developed within a multidisciplinary working group, two of whose members were also masters in the methodology of systematic revisions. The first step in the discussion was the identification of ethical and methodological problem. In a rapidly developing field, books are unlikely to be able to give updated information. One needs to interact with electronic databases. In this context, no randomized controlled trial on pregnancy is expected. The evidence is likely to be heterogeneous. Prenatal care delivery differs around the world in part related to attitudes toward pregnancy, which depend upon religion and traditions. The second step was the definition of the search strategy. The third step, was selecting and cataloging the evidence. The titles and abstracts retrieved by the search strategy (272 items) were examined to identify full papers to be retrieved. The evidence retrieved was screened for the type of paper (reviews, primary studies, case reports, case series) and for the authors to give an indirect idea of duplicate publication bias. Teaching a complex and ever-changing subject, such as kidney transplantation, is a difficult task. The case of a young woman seeking information on the probability to undergo a successful pregnancy was particularly likely to exemplify the importance of being aware of the biases of the book-based information and on the need to interact with the internet. The search strategy developed by the working group of postgraduate trainees allowed students to have a direct experience with the complexity of the field. This preliminary study, as the basis for development of a checklist informed consent form on pregnancy in kidney transplantation, may give a first rough quantification of the work needed by a physician who wants to have a direct idea of the odds and risks of pregnancy in kidney transplant patients.

Acute pyelonephritis is a common complication of kidney transplantation, occurring in up to 1% of grafts. Diagnosis is mainly clinical and atypical presentations have seldom been reported. The diagnostic role of imaging techniques has not been defined. Five cases of acute graft pyelonephritis are reported (three kidney, two pancreas–kidney grafts). The patients (median age 48 years) comprised three females and two males. Median post-transplant follow-up was 3 months, with three patients having predisposing factors for diabetes and one for an enteric bladder. None of the patients presented the ‘classic' diagnostic tetrad (i.e. fever, positive urine cultures, low urinary tract symptoms and serum creatinine increase); although, at diagnosis, two of five patients presented with fever, one had increased creatinine levels and one had positive urine cultures. Of note, three patients had leucocyte casts at urinary sediment analysis, thus raising clinical suspicion. Renal ultrasounds were negative in all patients. Renal 99m Tc-MAG3 (mercaptoacetyltriglycine) scintigraphy, which was used for the definition of kidney function impairment (one patient) or because of the presence of urinary casts (three patients), or after the biopsy diagnosis to locate the parenchymal lesions (one patient), was positive in all patients. The presence and pyelonephritic origin of the parenchymal lesions was confirmed by nuclear magnetic resonance or computed tomography scans. Acute graft pyelonephritis may develop in the absence of a full-blown clinical picture. Smouldering symptoms may occur in the presence of large perfusion deficits. 99m Tc-MAG3 scintigraphy could be an important diagnostic tool in such cases.

Among the so-called social risk behaviors, male homosexuality is probably one of the most interesting and difficult taboos. Because of changing attitudes of the general population toward irregular sexual behaviors, often considered as markers of unhealthy life styles, there is a need to reconsider at least the most important one-homosexuality.A semistructured questionnaire included opinions on homosexuality with respect to kidney donation: Would you consider a male homosexual as a kidney donor? If you were on dialysis, would you accept a kidney from a homosexual donor? This instrument was administered to various groups of the general public and caregivers: high school students (Liceo Classico: 59 students, median age 18 years; Istituto Tecnico: n=108, median age 17); first and fourth year of medical school (n=77, age 19; 46, age 22); continuing medical education (n=44, age 32); third year of nursing school (n=31, age 23); "senior citizen university" (n=51, age 63).Male homosexuality was well accepted for kidney donation (71.6% yes, 9.6% no, 18.8% uncertain/blank). However, the opinions were different among the groups with male students of a technical institute showing discrimination against male homosexuals. In the univariate analysis, opinions differed according to age, gender, and belonging to the health care team. In the multivariate analysis, the latter was the strongest predictor (P.01). The specific threats for the health are not well known, even among the caregiver population.It is difficult to define the role of homosexuality among the so-called social risk behaviors. Negative attitudes existed in some subsets of the population.

Context. Organ shortage for transplantation is a crucial problem; educational interventions may increase donations and decrease opposition. Objective. To test the efficacy of an educational programme on opinions on organ transplantation and kidney donation. Design and Participants. Cluster Randomized Controlled Trial: eight intervention and eight control schools were randomly selected from the 33 public schools that agreed to participate. Targets: students in the last 2 years of secondary school (17-18 years); seven schools per group completed the study. Educational programme. Intervention: first questionnaire (anonymous); 2 h lesson in each class; 2 h general session with patients and experts; second questionnaire. Control: questionnaires. Main outcome measures. Differences between questionnaires (comparative analysis); interest; satisfaction with the programme; (cross-sectional analysis). Results. 1776 first, 1467 second questionnaires were retrieved. Living kidney donation: at baseline 78.8% of students would donate a kidney to a relative/friend in need. The answers were unaffected by type of school but depended on sex (females more prone to donate, P

Dialysis patients often suffer from erectile dysfunction. The prevalence of this symptom in the context of dialysis is as high as 90%. Diabetes, diffuse vascular disease and pharmacological therapy are attendant causes of this condition, severely impairing the quality of life. Due to the high frequency of erectile dysfunction in uremic patients, minimalist diagnostic approaches are often used. Nevertheless, a careful differential diagnosis is also warranted in well dialyzed patients to identify causes and corrigible patterns. The case reported here exemplifies this critical issue. A 44 year old obese diabetic patient complained about the recent onset of erectile dysfunction. On examination, the penile echo-Doppler was normal, and suggested a cause other than dia-betic vascular disease. The high dialysis efficiency (daily hemodialysis, flexible schedules, EKRc from 15 to 25 ml/min) warranted the same diagnostic work-up as would adopted for non-uremic patients. Whilst the rising prolactine level (76.1 microg/l and 129 ng/ml) was still in the range commonly found in dialysis patients, a nuclear magnetic resonance examination was carried out and led to the identification of prolactinoma. Therapy with cabergoline was found effective and sexual potency was restored. Normalization of hormonal patterns followed within 2 months. This is the first case so far reported in a daily dialysis patient. It underlines the importance of a non-minimalist approach to the problem of sexual disorders in renal replacement therapy (RRT) patients, at least when dialysis efficiency is high and onset is rapid. It also suggests considering prolactinoma as an emerging diagnosis in the general population, which can be detected by the use of sensitive imaging techniques in the differential diagnosis of this condition.

Vascular lesions are an increasing challenge after renal transplantation due to the wider indications for recipients and acceptance criteria for donors. Diagnostic approach and prognostic interpretation are still matter of controversy. The case reported herein may summarize some of the issues in this regard. A 54-year-old woman, on renal replacement therapy since 1974, and a kidney graft recipient from 1975 to 1999, received a second graft in 2001. The donor age was 65 years (cold ischemia 22 hours; two mismatches). The early posttransplant follow-up was characterized by delayed graft function, hypertension, and diabetes. During the initial hypertension workup, renal graft ultrasound (US) Doppler demonstrated increased vascular resistances, stable over time (resistance index 0.74 to 0.77); renal scintiscan displayed homogeneously parenchymoa and angio-magnetic resonance imaging (MRI), an homogeneous parenchymal vascularization. Initial immunosuppression with tacrolimus and steroids was modulated by adding mycophenolate mofetil to taper tacrolimus (to reduce nephrotoxicity and hypertension). Despite this, kidney function slowly deteriorated; serum creatinine reached 3 to 3.5 mg/dL by the second year. After a severe hypertensive crisis with unchanged scintiscan and US doppler examinations, angio-MRI revealed the almost complete disappearance of parenchymal enhancement beyond the lobar arteries. A renal biopsy confirmed the severe vascular damage. The patient was switched to rapamycine and a low-dose of an angiotension converting enzyme (ACE) inhibitor. She did relatively well (serum creatinine 2.2 to 3 mg/dL) for 6 months, when rapid functional impairment forced her to restart hemodialysis. This case, almost paradigmatic of the problems occurring when the rigid vasculature of long-term dialysis patients is matched with “marginal kidneys,” suggests that MRI may be a sensible good to define vascular damage in the grafted kidney.

The discrepancy between the supply of organs fortransplantation and the clinical demand for them isa crucial issue in nephrology. To overcome this gap,several policies have been implemented to increasethe general public’s knowledge and awareness of theproblem; accordingly, Italian law requires that trans-plantation medicine and end of life issues be discussedin high school [1,2].In publicity or educational campaigns, the use ofimages to communicate core concepts is crucial to thesuccess of any such initiative [3,4]. Furthermore, acommercial advertising campaign is usually precededby a detailed market analysis and a study of the bestway to present the product [5]. This approach iscommonly employed by medical suppliers, and greatattention (possibly too great) is paid to carefullyadvertising new drugs and products—with the exten-sive use of gadgets, gimmicks and colourful brochuresin the process. In contrast, educational campaigns oncrucial social issues, such as renal transplantation ororgan donation, often are planned without help fromexperts working directly in the relevant professionalfields and without analysing the opinions of the targetpopulation or ‘consumers’ (in this case, the patientsand donors), often also without substantial help frompublic relation experts.Few of us nephrologists have the opportunity tolearn and discuss how our work is ‘viewed’ by personsnotaffectedbyrenaldiseaseorbythoselinkedtousonlysocially (i.e. friends or non-professional relationships).With the preceding as background, the present experi-ment was conducted in an artistic high school inconjunction with its participation in a city-wide educa-tional programme for high school students that wasrun by the Section of Nephrology of the University ofTurin. This was an appropriate occasion to evaluatethe way young people conceptualize the ‘idea’ of renaltransplantation and how they would choose to com-municate the ‘life and death’ concepts of renal replace-ment therapy, a crucial point in educational campaigns[6]. For this purpose, we organized a competition thatwas included in that school’s programme.Here we report on the results of the competition.

Background The negative impact of the mass media, the lack of information, and the request for in-depth knowledge are the basis for the present need for educational programs on transplantation, brain death, and chronic kidney diseases end-stage renal disease; (ESRD). The aim of the present article was to critically review the activities performed by Il Gallo di Esculapio, a nonprofit association, in the education on the different phases of ESRD. The associates are physicians and patients, and the activities are integrated institutionally. Methods This report is a narrative review of the material produced and performed by Il Gallo di Esculapio ONLUS in 1996–2004. Results The two main activities developed were book writing and an educational program. Eight books for patient education were written on different aspects of dialysis, transplantation, and ESRD. Most were designed as theses of the Medical School. Cooperation with patients was important in all cases and fundamental for the collection of interviews. Education A 4-hour educational program on transplantation started in 2000–2001 (1 high school was involved). The checklist originally included only transplantation and organ donation, but progressively gave space also to dialysis, ESRD, and social health care problems. In 2003–2004 the program involved 67 high schools. The association coordinated progressive patient involvement. Conclusion Small, nonprofit patient-physician associations linked with the University allow enrolling resources for educational activities to often-neglected parts of the medical profession.

Wegener’s granulomatosis is a rare, protean disease,with even sex distribution and higher incidence inCaucasians. Its yearly incidence is 5–12 per 1000000[1] and it displays a wide range of clinical presenta-tions from a mild, localised lesion to widespread severedisease [2].The age range is wide, with the peak in the 40s.Women in the childbearing age group are not spared,and pregnancy presentsa critical condition both for theonset of the disease and for its flare-ups [2,3].The decision of a patient with Wegener’s granulo-matosistobecomepregnantpresentsaclinical dilemma[3]. To face it in the era of evidence-based medicine(EBM) and of patients’ right of self-determination,two tools, systematic literature search and physician–patient therapeutic alliance, were used together (asrecently suggested), integrating narrative and EBMproblem solving approaches [4].To address a patient’s questions, the search strategyshown in Table 1 was performed on Medline andEmbase, combining terms (Mesh–Emtree and freeterms) referring to Wegener’s granulomatosis andthose related to pregnancy.In all, reports on 28 pregnancies were retrieved(Table 1); outcome data were available for 27 of those.The diagnosis of Wegener’s granulomatosis occurredin pregnancy in eight out of 28 patients; 19 out of 27pregnancies ended in live births, seven in abortionsand two in maternal deaths (Table 1).In the reviewed literature, the most commonadvice was to not start a pregnancy in the presenceof active disease: with a clear note of caution expressedin all cases. The quality of the evidence available, how-ever, was poor, consisting of case series and casereports, presumed to be tainted by publication biases;however, such biases affect the study and discussion ofall rare diseases, especially if, as in the case of preg-nancy, the condition cannot feasibly be randomizedfor study.The present updating, performed after the patientsdecision, added only one paper to the ones retrieved bythe search strategy performed at patients referral [5].

Background Informed consent is crucial in therapeutic choices; however, the forms presented to patients are often locally developed and information may not be homogeneous. Objective To prepare an evidence-based model for informed consent, applied in the case of erythropoietin therapy (EPO) as a teaching tool for medical students. Methods Methodological tools of Evidence-Based Medicine (EBM) were developed within the EBM Course in the Medical School of Torino, Italy, as problem solving and patient information tools (5th year students work in small groups under the supervision of statisticians, epidemiologists and experts of internal medicine - nephrology in this case). Results Methodological and ethical problems were identified: in the pre-dialysis field, evidence from randomized clinical trials (RCT) is scant; how to use evidence gathered in dialysis? How to deal with implementation? How with the mass media? Do we need to discuss the drug choice with the patients? How to deal with rare and severe side effects?). The “evidence” was searched for on Medline/Embase, by using key-words and free terms. About 680 papers were retrieved and screened. Forms available on the Internet were retrieved and a general scheme was drawn: it included 5 areas: title, aim and targets (patients and family physicians); search strategies and updating; pros and cons of therapy; alternative options; open questions. Conclusions EBM may offer valuable tools for systematically approaching patient information; the inclusion of this kind of exercise in the Medical School EBM courses may help enhance the awareness of future physicians of the correct communication with patients.

There are good epidemiological (increased numbers of dialysis patients), economical (renal replacement therapy (RRT) costs) and clinical reasons (new highly efficient schedules) to reconsider the choice of home hemodialysis (HD).Analysis of the results and costs of a flexible, tailormade home dialysis program (1998-2003).Home HD facility of the University of Turin-Italy.Results were analyzed in terms of feasibility (enrolment rate, logistical problems--the two usual caregivers performed a retrospective analysis of the clinical records; production costs, assessed with a logic bottom-up technique). Since the main program feature was the tailoring of dialysis to the patient, kinetic data were analyzed to control the efficiency of the chosen schedules.In 1998-2003 (54 months), 31 patients joined the home HD program (six patients were already being treated), while another 12 patients were treated in the training area and trained for an ongoing self-care program; mean age was 47.1 +/- 12.8 yrs; 35/49 patients had clinical comorbidities. During the study, four patients died, 10 were grafted, and six patients dropped out or were transferred. In March 2003, 23 patients were at home/in training and six were being treated in the training area: 11 patients were on a conventional schedule, four on daily dialysis, 12 on other schedules (two patients non-resident in the Piedmont region were not considered). Dialysis efficiency reached the target (EKRc11 mL/min) in all but four patients (schedules with more frequent sessions were planned for these patients). Costs were comparable to limited care HD (daily: 96.5 euros/session at home, 98.76 euros/session in the center; conventional: 133.48 euros/session at home, 131.25 euros/session in the center).A tailored, flexible policy can help to revive a home HD program.

Organ shortage for transplantation has focused attention on educational interventions. Italy is a nonhomogenous country whose cultural and economic differences are reflected in the health-care system: dialysis is mainly public in the north versus private in the south; and transplantation rates display a wide range from 3.4 to 37.8 per million people in 2002. The aim of the present study was to analyze the opinions of population of high school students (last two years) in two large cities: northern (Torino) and southern (Napoli) Italy, as a knowledge base for a randomized controlled trial on the efficacy of educational interventions on renal replacement therapy and organ donation, targeted to high school students. Methods This preliminary study included eight public high schools that completed a first and anonymous semistructured questionnaire. Five hundred and eighty nine questionnaires were retrieved in Torino and 539 in Napoli. In both cities most students answered that they would give a kidney to a brother, sister, or partner needing dialysis (Torino: yes 80.6%; no 2.2%, uncertain—blank 17.2%; Napoli: yes 86.1%, no 1.1%; uncertain—blank 12.8%). Only 36.3% of the students in Torino and 37.7% in Napoli answered that they would consent to organ donation, if they had to choose for a strict relative with brain death. Opposition was 28% in Torino and 23.7% in Napoli; 35.7% in Torino and 38.6% in Napoli were blank—uncertain. These data underline the need for detailed information on the opinions of the overall population as basis for tailored educational campaigns.

Background Continuing Education in Medicine (CEM) underlines the importance of updates and information for the health care team. Our aim was to describe the organization and results of a CEM course “educate to organ donation” that involved the nursing team in an educational experience with high school students. The course consists of theory (4 hours; the physician–patient relationship, the educational role of the nurse, the teaching policy, checklist, and results of a school education program) and practice (10 hours; the attendants join the teaching team in the classrooms and in the plenary session). Analysis of anonymous questionnaires performed after the course contained semistructured questions and analog scales. Results The first acknowledgment came from the Cabinet of Public Health, which gave the maximum number of credits (14 for 14 education hours). Participation: presently 40 nurses, about 40% of those working in the renal unit (over 30 CEM courses are available in the hospital). Satisfaction: Overall score was median 8.5 (6 to 10) including teaching materials = 8 (4 to 10). Among the theoretical part, the lesson on patient–physician relationship obtained the highest score. The main drawback was the shortness of the practical part. The classroom meeting achieved a median score of 9.5 (7 to 10), the general session = 9 (5 to 10). All but one nurse registered for an “advanced” course, giving more time to the practical part (20 hours). Conclusion CEM may represent an important way to deliver education on transplant-related issues to patients and to the general population.

BACKGROUND: Pre-emptive pancreas-kidney transplanttation is increasingly considered the best therapy for irreversible chronic kidney disease (CKD) in type 1 diabetics. However, the best approach in the wait for transplantation has not yet been defined. AIM: To evaluate our experience with a low-protein (0.6 g/kg/day) vegetarian diet supplemented with alpha-chetoanalogues in type 1 diabetic patients in the wait for pancreas-kidney transplantation. METHODS: Prospective study. Information on the progression of renal disease, compliance, metabolic control, reasons for choice and for drop-out were recorded prospectively; the data for the subset of patients who underwent the diet while awaiting a pancreas-kidney graft are analysed in this report. RESULTS: From November 1998 to April 2004, 9 type 1 diabetic patients, wait-listed or performing tests for wait-listing for pancreas-kidney transplantation, started the diet. All of them were followed by nephrologists and diabetologists, in the context of integrated care. There were 4 males and 5 females; median age 38 years (range 27.9-45.5); median diabetes duration 23.8 years (range 16.6-33.1), 8/9 with widespread organ damage; median creatinine at the start of the diet: 3.2 mg/dl (1.2-7.2); 4 patients followed the diet to transplantation, 2 are presently on the diet, 2 dropped out and started dialysis after a few months, 1 started dialysis (rescue treatment). The nutritional status remained stable, glycemia control improved in 4 patients in the short term and in 2 in the long term, no hyperkalemia, acidosis or other relevant side effect was recorded. Proteinuria decreased in 5 cases, in 3 from the nephrotic range. Albumin levels remained stable; the progression rate was a loss of 0.47 ml/min of creatinine clearance per month (ranging from an increase of 0.06 to a decrease of 2.4 ml/min) during the diet period (estimated by the Cockroft-Gault formula). CONCLUSIONS: Low-protein supplemented vegetarian diets may be a useful tool to slow CKD progression whilst awaiting pancreas-kidney transplantation.

Recently increased attention for chronic renal failurehas stimulated new interest in renal function assess-ment by direct measurement as well as by algorithmsor formulas [1–3]. In the failing renal graft, a situationin which pharmacological therapy may interfere withthe complex adaptation mechanisms of renal failure,the assessment of renal function may be particularlydifficult [4]. Studies of patients with liver or hearttransplantation and advanced kidney disease suggestthat creatinine-based indexes may be poor indicatorsof residual renal function under calcineurin inhibitors[5,6]. The following two cases, displaying a discrepancybetween creatinine and urea clearances, draw attentionto this rather neglected, yet clinically relevant, aspectof renal function assessment.

Background The attitude toward living donation varies widely in the world, for economic and cultural reasons. In Italy, as in other Mediterranean settings, the role of living kidney donation is minor. Aim To analyze the reasons for this attitude, we gathered data in a general population sample of high school students in a large northern Italian industrial city (Torino, about 900,000 inhabitants). Methods Semistructured questionnaires (n = 1676), gathered in 2001 to 2002 in 14 high schools, in the context of an educational program on dialysis, renal transplantation, and organ donation, were analyzed presumably reflecting opinions gathered before the educational intervention. Results Most students, in the case of a close relative or partner needing dialysis, answer that they would donate a kidney (yes: 78.2%, no: 2.9%, uncertain—blank: 18.9%); receiving a living donor kidney is felt as disturbing: only 57.5% of the students would accept it (no: 5.9%, uncertain—blank: 36.6%), mainly because of fear of long-term problems for the donor. Donation from an older to a younger person is seen more positively than vice versa. Conclusion In our settings, the attitude of the teenagers on living donation is positive; however, while “giving” is positively seen, the presence of unresolved fears is witnessed by the lower acceptance of the idea of “taking.” These data suggest to focus on the risks of kidney donation in educational campaigns and in patient-physician information. The positive attitude shared by the teenagers supports the working hypothesis that lack of information is one of the determinants of the low living donor transplantation rate in our area.

The aim of this study was to report on the production and the opinions of a video movie on transplantation and organ donation. The video was developed by a medical school student with the help of the students and teachers of a high school for applied arts. For this task, the making of the video was included in the high school program of the participating class. The students were tutored by their photography teacher. The video movie lasts about 50 minutes. Each “scene” lasts no more than 5 minutes, to avoid reducing the attention level. The choice of a nonmedical frame helped to have some moments to digest the technical information and to stress the importance of the patient–physician relationship. The video was employed as a part of small-group lessons in the nephrology course. A semistructured anonymous questionnaire gathered the opinion of 65 students at the end of the lessons. Student satisfaction was high; the median score was the highest (8, range 6 to 10) for the lesson based upon the movie, as compared with the conventional ones on chronic kidney disease or dialysis (7, range 5 to 10). As far as the authors know, this is the first experiment of a multimedia approach, dedicated to medical and nonmedical targets, developed as a graduation thesis in an Italian Medical School. In conclusion, the positive opinions of the students, who highly appreciated the peer-developed message, may suggest implementing such nonconventional educational approaches to support human resources and enthusiasm for kidney transplantation among the new generations.

Background In this era of globalization, in which different cultural and economic barriers are progressively abated, in the context of the development of rapid information networks such as the Internet, physicians are increasingly challenged by clinical and ethical questions. Kidney vending, banned in some countries, legal or tolerated in others, may be the prototype of the ethical aspects of health-care globalization. Methods To test the interest and the opinions of medical school students, a simulated case was proposed to students attending a seminar within the nephrology course fourth year of the Medical School of Torino, san Luigi): an Italian patient comes to the nephrologist's office asking for advice on the possibility to legally buy a kidney in a foreign country. The 43 students attending the lesson answered a semistructured questionnaire (15 boys, 28 girls, of median age 23 years). Attendance was within the usual standards (50 students inscribed per year). From the clinical point of view, 11.6% were favorable to kidney vending, 51.2% were contrary, 37.2% were uncertain. From the ethical point of view, no student was pro, 81.4% were contrary, and 18.6% were uncertain. The open comments underline the importance of patient self-determination and of informed consent. Similar opinions were recorded in a nonstructured question: “What should physician's attitude be, in the face of a choice he/she doesn't share?” Conclusion Students' uncertainties and doubts underline the need to discuss ethical scenarios in the clinical teachings of the medical school.

Keywords: aortic aneurism; atherosclerosis; endo-prothesis; daily haemodialysis; long-term RRTThe impressive calcifications seen in the computedtomography (CT) reconstruction of an aortic aneur-ysm of the abdominal aorta in Figure 1 belong to a 48-year-old male, on renal replacement therapy (RRT)from the age of 22. His end-stage renal diseasewas membrano-proliferative glomerulonephritis withsevere and prolonged nephrotic syndrome. In 1981,3 years after diagnosis, he started RRT on peritonealdialysis; he was switched to haemodialysis in 1985 dueto functional exhaustion of the peritoneum, and acadaveric graft was performed in 1993. Haemodialysiswas resumed in 1996 after graft failure due to recurrentmembranous and proliferative glomerulonephritis,again with severe nephrotic syndrome. He hadhypertension, usually well controlled by multipledrug therapy, parathyroidectomy because of severehyperparathyroidism unresponsive to conservativetreatment (1993) and a coronary by-pass (1997). Theaortic aneurysm shown in Figure 1 was first diagnosedin 1991: at that time, the maximum diameter was4.2cm. The diameter was stable until March 2000,when it increased to 4.6cm and further to 4.8cmin November 2000, despite a daily haemodialysisschedule (started in 1999), minimizing weight lossper dialysis and with a good blood pressure controlwithout need for drug therapy.Balancing the young age of the patient and thesurgical risks due to the diffuse arterial calcificationstypical of uraemic patients (Figure 2), a percutaneousendoluminal approach was chosen and successfullyperformed in January 2001, employing a modular

Background. Interest in the humanities in the medical school is growing; while several medical schools, mainly of Anglo-Saxon background, have developed dedicated courses, the experience in Italy is limited. Methods. Since the academic year 2000 to 2001, a discussion of ethical problems was implemented in the nephrology course (fourth year of the Medical School of Torino, Italy; overall 6 years). In 2002 to 2003, a case entitled Retransplantation of Multiple Organs (Prog Transplant 2002) was discussed in 2 hours of small-group tutorial teaching: a boy received a renal graft at age 5, failed at age 7 due to recurrent glomerulonephritis, required a heart-kidney graft at age 11, and a second heart-kidney graft at 17. Student opinions were gathered by anonymous semistructured questionnaires at the beginning of the lessons as a basis for discussion. Results. Following the lessons all students returned the questionnaires (n = 104). In the absence of competition for allocation, retransplantation was approved by 76.2%, unacceptable for 1% (22.9% uncertain-blank). With a waiting list of 10 patients, the opinions changed: 32.4% approved transplantation, 6.7% didn't approve it, 60.9% were uncertain. A theoretical categorization into deontological or utilitaristic approaches favored the first (41.9% vs 26.7%), with a high prevalence of blank-uncertain (31.5%); 21.9% of the students would change their opinion was that study head of the Transplant Department. Conclusion. Ethical aspects of the medical profession have been discussed with interest by medical school students; the high prevalence of uncertain answers and requests to develop specific tools underline the importance of this educational approach.

Aim Organ shortage is a rate-limiting factor for transplantation. The aim of this study was to evaluate the impact of an educational program targeted to high school students on opinions concerning organ donation. Methods Sixteen public high schools in Torino, Italy, were randomized (2001 to 2002) as interventions ( n = 8) or controls ( n = 8). Intervention was composed of first questionnaire, first lesson (one to two classes; 2 hours, by a trained nephrology fellow); second lesson (all classes together; coordinated by a nephrologist, with patients and trainees); second questionnaire. Control included questionnaires. Statistical analysis compared the opinions in the questionnaires after stratification for age, sex, and type of school. Results Fourteen schools completed the program (seven interventions: 937 first and 808 second questionnaires; controls: 739 and 659). Television (82.5%) and newspapers (43.2%) were the main sources of information; knowledge on renal transplantation (grafts feasible per patient, average duration) was low; only 12.2% of the students gave correct answers. The opinions on living donation were highly positive (76.8%) with no difference in control, intervention schools, first and second questionnaires, according to sex, age, or type of school. The opinions on cadaveric transplantation were affected by the educational intervention with a drop in negative answers (from 33.7% to 16%), with an increase in positive (from 31.5% to 42.9%) and in uncertain ones (from 34.8% to 41.1%) among the intervention schools; 98% of the students appreciated the program. Conclusion The positive effect on student opinions suggests the need to develop educational approaches as a part of our routine clinical work.

Background Nephrotic syndrome due to diabetic nephropathy is presently considered an indication for pancreas-kidney transplantation even in the absence of severe renal failure. Reversal of the nephrotic syndrome has been reported, but the mechanisms of this effect are unclear. Aim To describe the renal morphofunctional pattern and the pattern of proteinuria before and after preemptive pancreas-kidney transplantation. Methods Methods included quantitative and qualitative assessment of proteinuria as well as renal ultrasound and scintiscan. Case report A 42-year-old woman with type 1 diabetes since age 24 had widespread end-organ damage. Renal biopsy (2001) showed a mainly nodular pattern of diabetic nephropathy. Following referral (1999), her serum creatinine ranged from 1.6 to 2.2 mg/dL, with nephrotic range proteinuria (glomerular nonselective, tubular complete). Renal scintiscan revealed bilateral, symmetric, well-perfused kidneys. The functional data before pancreas-kidney graft (February 2003) were: serum creatinine 1.6 mg/dL, creatinine clearance 58 mL/min, serum albumin 2.6 g/dL, proteinuria 9.1 g/d. At hospital discharge (March 2003), the creatinine was 1.2 mg/dL, the creatinine clearance 97 mL/min, the proteinuria 0.676 g/d. Two months later, the creatinine was 1.2 mg/dL and proteinuria 0.421 g/d. A renal scintiscan demonstrated the functional prevalence of the grafted kidney (77% of total function), with vital, almost completely excluded native kidneys (functional contribution, 11.5% each). Proteinuria, ranging from 0.3 to 0.6 g/d, showed a physiological pattern. Conclusions Functional exclusion of the native kidneys by renal scintiscan gives morphological support to reversal of the nephrotic syndrome.

Survival has been defined as an index of adequacy of dialysis. These hard data are the basis for comparing results obtained by different schedules or policies. The aim of the study was to assess mortality rate recorded within a system of tailored dialysis (1–6 dialysis per week in out-of-hospital settings: home hemodialysis, self- and limited care dialysis). Data recorded in a single center (1998–2003) were compared with data gathered in the Registry of Dialysis and Transplantation in the whole Region (1998–2000). Methods: Out-of-hospital dialysis unit is active since 1971, in which a new program integrating self- and limited care and home dialysis started since 1998. Patients: Incident dialysis patients starting renal replacement therapy within the program and all further patients starting dialysis in the Region in the same period were compared in an historical prospective cohort study. Results: 55 patients in the Unit and further 1443 patients in the whole Region started RRT since 1998. Main features of 55 patients were 32 males 23 females; median age 51 years, range 20–76; 72.7% displaying at least 1 comorbid factor. Throughout the period gross mortality rate was 4/125 patient-years in the Center. Kaplan–Meier curves showed a 1-year survival of 100% vs. 91%, respectively, in the Center and in the whole Region, and a 2-year survival of 95.5% vs. 76.6%, respectively, in the Center and in the whole Region (p = 0.001). The main demographic features were remarkably different in both settings (for the whole Region median age 66 years, range 2.2–101, at least 1 comorbidity in 56.9% of patients). In an attempt to correct for the different baseline characteristics, a multivariate Cox regression analysis was performed. The whole model resulted in statistically significant value (p = 0.000) and an increasing mortality risk resulted for age at starting dialysis, diabetes, and collagenopathy. In conclusion, tailored, high-efficiency dialysis policy may allow superior survival results. A longer follow up is needed to confirm our approach; in larger cohorts, the finding of a low mortality rate in a relatively young population with high comorbidity may underline the need to review our current concepts on dialysis adequacy.