BACKGROUND: Early referral is a major goal in chronic kidney diseases; however, loss to follow-up, potentially limiting its advantages, has never been studied. MATERIAL/METHODS: In order to assess the prevalence and causes of loss to follow-up, a telephone inquiry was performed in a renal outpatient unit, mainly dedicated to early referral of diabetic patients. Patients were considered to be in follow-up if there was at least one check-up in the period February 2001-February 2002, and lost to follow-up if the last check-up had occurred in the previous year. The reasons for loss to follow-up were related to typical clinical-biochemical parameters to define a "drop-out profile". RESULTS: 195 patients were on follow-up: median creatinine 1.4 mg/dL, age 64, 76.9% diabetics. 81 patients were lost to follow-up: creatinine 1.4 mg/dL, age 70, 73.8% diabetics. A telephone number was available in 87.6% of the cases; 25 were not found, 7 had died, 24 were non-compliant, 1 was bed-ridden, 12 had changed care unit, 2 had started dialysis. Renal care was shorter in those lost to follow-up; among the latter, serum creatinine and age were significantly lower in non-compliant patients. A logistic regression model confirmed the significance of lower serum creatinine at last check-up in non-compliant patients (p=0.018). CONCLUSIONS: Loss to follow-up is a problem in nephrology; lack of awareness probably causes the higher drop-out rate at lower creatinine levels. The initial period of care may be crucial for long-term compliance. Further studies are needed to tailor organizational and educational interventions.

Aged↗

PubMed2002

Early referral of Type 2 diabetic patients: are we ready for the assault?

BACKGROUND: Elderly diabetics on dialysis are dramatically increasing in number. Their late referral reduces efficacy of therapeutic interventions; early referral is fundamental for their survival on dialysis. However, need for nephrological follow-up in case of early referral is not assessed. The objective was to define the need for follow-up in the nephrology setting of Type 2 diabetics, according to the early referral criteria of serum creatinine > or = 1.5 mg/dl or macroproteinuria. METHODS: The setting of the study was an outpatient diabetic care unit (University of Torino), where approximately 25% of the Type 2 diabetics of a 900,000-inhabitant city (Torino, Northern Italy) were followed. At the time of the study (1998-1999) the unit followed 5182 Type 2 diabetics whose serum creatinine and proteinuria were tested at least yearly. A total of 3826 prevalent and 478 incident patients with one or more analyses in the same laboratory were included in the study. Demographic data were not statistically different between selected and excluded patients. We calculated the stepwise need for nephrological follow-ups calculated according to our usual policy (4-12 evaluations/ year, on serum creatinine and proteinuria, and 30 min/evaluation). RESULTS: The prevalence of increased serum creatinine and macroproteinuria was high (in the prevalent cohort: serum creatinine > or = 1.5 mg/dl, 8.1%; proteinuria 0.3 g/day, 25.2%; serum creatinine > or = 3 mg/dl, 1.2%; nephrotic proteinuria 3.4%). Projecting data to the entire unit, with adherence to our evaluation protocol, early nephrological follow-up of Type 2 diabetics requires approximately 1300 h/year (one full-time nephrologist); five nephrologists are needed for our city, and 24 for the region (4350 000 inhabitants). CONCLUSIONS: Early nephrological referral and follow-up of Type 2 diabetics is time consuming and expensive. Meeting the outpatient care needs of this critical cohort requires considerable resources.

Biomarkers↗

PubMed2002

Patients on renal replacement therapy for 20 or more years: a clinical profile.

BACKGROUND: Long-term survivors are living evidence of the goals and limits of renal replacement therapy (RRT). METHODS: A cross-sectional study was performed on all cases (188 patients) with RRT follow-up >/=20 years in Piemonte, northern Italy (4 350 000 inhabitants, 22 dialysis centres). Study included revision of clinical charts and assessment of functional (Karnofsky scale, Ks) and nutritional status (subjective global assessment, SGA). According to treatment history, patients were sorted into three groups: group 1, 56 patients always on dialysis; group 2, 40 patients on dialysis with previous graft; group 3, 92 grafted patients. RESULTS: Age differed between group 1 and groups 2 and 3 (59.5+/-11.5 vs 51.5+/-7.9 and 51.0+/-9.0 years; P=0.001). Prevalence of comorbidity was higher in groups 1 and 2 (94.6% and 95%) compared with group 3 (81.5%), reflecting selection during follow-up. Twenty-two cases (11.7%) had no comorbidity; these patients were younger (44.3+/-8.5 years) and 17 out of 22 had a functioning graft. The most common comorbidities were vasculopathy (73.4%), bone disease (72.9%) and cardiopathy (33.5%). Severe visual impairment was a common problem (18%), with a higher prevalence in patients with cardiovascular comorbidity (32%). Severe depression was found in 13.3% of cases. Despite comorbidity, functional scores (Ks) were good (higher in group 3 (88.1+/-15) than in groups 1 and 2 (67.9+/-21.9 and 75.5+/-18, respectively); P=0.000) and 64% of patients were well nourished. The combination of cardiovascular comorbidity, bone disease and visual impairment may reflect the premature ageing of RRT patients. CONCLUSION: Despite the high prevalence of comorbidity, long-term follow-up may promote good clinical conditions at least in some patients, highlighting the therapeutic potentials of dialysis in an era of reconsideration of open acceptance of RRT.

Adult↗

PubMed2002

Home hemodialysis. Revival of a superior dialysis treatment.

BACKGROUND: Home hemodialysis is usually considered a superior therapy, whose decline is related to demographic, social, psychological and financial factors as well as to competition with renal transplantation and PD. METHODS: A home hemodialysis program was started in November 1998 in the University of Torino, Italy (200-210 patients on dialysis). Its main features are the tailoring of dialysis schedules and the acceptance of patients with comorbidity. Nurses assist home sessions in case of short-term problems, while the training center ensures follow-up for long-term clinical and logistic problems. RESULTS: The program started in November 1998 on a previous one (active from 1970 to 1998; 6 patients on treatment in November 1998). Since then, 25 more patients joined the program. Out of 31 patients followed since November 1998, 4 were grafted, 2 died, and 2 dropped out from training. In June 2001, 15 patients were on home hemodialysis, 8 on training. Dialysis schedules and controls are flexible and tailored; in June 2001, range of dialysis time was 1.20-5 h; sessions: 2-6; 8 patients were on thrice-weekly dialysis, 7 on daily dialysis; all patients reached target EKRc >10 ml/min (median 15, range 11-24 ml/min). CONCLUSION: Tailored, flexible schedules allowed home hemodialysis in over 10% of our patients, confirming that there is still room for this treatment in our setting.

Adult↗

PubMed2002

Acute digital gangrene in a long-term dialysis patient -- a diagnostic challenge.

BACKGROUND: Vascular complications are frequent in long-term dialysis patients. The differential diagnosis is complex and includes immunological derangement (underlying disease, uremia), vasculopathic-atheroembolic diseases, calciphylaxis, infections, neoplasm, coagulation disorders, and adverse drug effects. CASE REPORT: We report on a 50-year-old male patient with a long follow-up on renal replacement therapy (20 years), currently on daily hemodialysis. The patient's history of kidney transplantation was complicated by seven acute rejection episodes and by Kaposi sarcoma; comorbidity included HLA-B27 positive ankylosing spondylitis, diffuse vascular disease, recurrent atrial fibrillation, chronic hypotension, HCV positivity. Ten days after the start of warfarin for an atrial fibrillation episode, the patient developed digital necrotising ulcerations, rapidly evolving into partial symmetric digital gangrene at distal phalanxes. The timing and evolution of the lesions and the finding of protein S deficiency were the clues for diagnosing warfarin-induced skin necrosis (WISN); the drug was discontinued and therapy with low-molecular weight heparin, plasma and prostacyclin achieved slow resolution of lesions. CONCLUSIONS: According to a combined MEDLINE and EMBASE search, this is the first report of WISN in a hemodialysis patient: underlining the clinical relevance of this uncommon problem, this case exemplifies the difficult differential diagnosis of acute vascular skin lesions in dialysis

Anticoagulants↗

PubMedDate not supplied

Ankylosing spondylitis: a difficult diagnosis in patients on long-term renal replacement therapy.

We report the case of a 48-year-old male, whose musculoskeletal manifestations, previously related to long-term renal replacement therapy (RRT), were diagnosed as ankylosing spondylitis when symptoms changed their pattern on daily hemodialysis (DHD). The patient started RRT in 1981; in 1985 he received a cadaver graft, which failed in 1987. Secondary hyperparathyroidism, amyloid geoids, bilateral carpal tunnel syndrome and high aluminium levels were present. Musculoskeletal pain, reported since 1986, involved feet, heels, hips, shoulders, hands, spine. Symptoms impairing daily life did not improve after parathyroidectomy. He developed chronic hypotension and recurrent atrial fibrillation. In 1994 and 1998, because of thoracic pain, coronarography was performed (normal on both occasions). In June 2000, DHD was started. Equivalent renal clearance increased from 9-12 to 15-17 mL/min. Well-being remarkably improved. In September 2000, musculoskeletal pain worsened and bilateral Achilles tendinitis occurred. The worsening of musculoskeletal symptoms despite the improvements in well-being and other dialysis related symptoms prompted a re-evaluation of the case. The diagnosis of ankylosing spondylitis was based on: history of plantar fasciitis, bilateral Achilles tendinitis, inflammatory spinal pain with limitation of lumbar spine mobility (positive Schober test), radiological evidence of grade 2 bilateral sacroiliitis, presence of HLA-B27. This diagnosis cast light on the episodes of chest pain, explained by enthesopathy at the costosternal and manubriosternal joints and atrial fibrillation, due to HLA-B27 associated impairment in heart conduction. This case exemplifies the difficulty of differential diagnosis of multisystem illness in patients with long RRT follow-up.

Atrial Fibrillation↗

PubMedDate not supplied

Kidney rupture: an unusual and oligosymptomatic complication in a dialysis patient with acquired cystic disease.

Acquired cystic kidney disease (ACKD) is a complication of end-stage renal disease, the prevalence of which is related to dialysis duration; incidence of ACKD and associated conditions (neoplasia, hemorrhage) have decreased with improvements in renal transplantation and with the ageing of the dialysis population. This report regards spontaneous kidney rupture in a 57-year old patient, on home hemodialysis for 11 years, with ACKD for 5 years. At the end of a dialysis session, the patient reported sudden onset of colicky flank pain, followed by macrohematuria. Pain remitted with low doses of pain relievers, leaving dull flank discomfort. The patient self diagnosed a renal colic, and called the hospital two days later. At referral, two large hemorrhagic renal masses (7 and 2.8 cm) were found at ultrasound and CT scan. At surgery, kidney rupture was diagnosed. This case highlights the life threatening complications associated with ACKD, and underlines that massive renal hemorrhage may occur with relatively minor symptoms.

Follow-Up Studies↗

PubMedDate not supplied

Tailored dialysis for diabetic patients: a tool for autonomy and efficiency.

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Adult↗

PubMedDate not supplied

Biochemical and microscopic urinalysis: time and cost in a nephrology laboratory.

BACKGROUND: Urinalysis is a fundamental test in internal medicine and nephrology. Figures for costs are available in the general laboratory, where biochemical and microscopic urinalysis are commonly performed as semiautomated screening tests. Information on costs is lacking in the nephrology laboratory, where a time-consuming morphological analysis is usually preferred. This study analyses the costs of urinalysis in a nephrology laboratory. METHODS: In the nephrology laboratory at the University of Turin - Italy, biochemical urinalysis consists of multi-property strip and proteinuria/creatininuria, done by laboratory technicians. Phase-contrast microscopy is done by a nephrologist or biologist. Time dedicated to the tests was recorded by the same operator over 20 working days, during which 350 urine samples were processed (median 19/day, range 842). The production costs were calculated with the logic bottom-up technique. RESULTS: Overall time needed was 11.9 minutes/sample. Biochemical urinalysis required 6.6 minutes/sample; time required and samples processed were inversely related (< or =19 samples: 7.95 minutes/sample; >19 samples: 5.6 minutes/sample, p=0.01). Microscopic urinalysis took 5.3 minutes/slide; the best time-to-samples ratio was at 18-22 samples per day (with peak efficiency at 21 samples: 4.6 minutes). Cost of reagents and disposables was Euro1.06/sample. Time accounted for euro 5.32/sample (technicians, nephrologist-biologist), with total direct cost of euro 6.38/sample. CONCLUSION: In a nephrology laboratory, microscopic urinalysis is a time-consuming, expensive test. Analysis of cost and modalities may be useful, in a time of budget constrains, to maintain a role for this precious semeiotic art.

Chemistry, Clinical↗

PubMedDate not supplied

Flexibility as an implementation strategy for a daily dialysis program.

BACKGROUND: Daily hemodialysis (DHD) is an interesting dialysis option, experienced worldwide by only a few hundred patients, because of clinical and logistic limitations. This study describes the main clinical and implementation results of a flexible policy applied in starting a DHD program. METHODS: The setting is the University Nephrology Center of Turin, Italy (approximately 150 hemodialysis and 50 peritoneal dialysis (PD) patients) where in November 1998 a short daily DHD program was started. Outcome measures were logistical (enrollment rate, indications and drop-outs) and clinical (dialysis efficiency, metabolic control, hypertension and anemia control). RESULTS: 25 patients experienced DHD, 16 (11% of the hemodialysis pool) were on DHD in November 2001; overall the DHD follow-up was 409.1 months (median 18, range 0.7-36 months). Flexibility was applied to schedules (patients modulated dialysis time and could switch to 3-4 sessions/wk); treatment setting (home: 11 patients, limited care center: 13; alternate settings: one); clinical selection (23/25 patients with comorbidity). Main reasons for choice were poor tolerance of previous schedule and the search for "best" treatment. Five patients dropped out (work reasons), one died on DHD and three were grafted. As compared to baseline, dialysis efficiency increased (EKRc pre-DHD 14.5 +/- 2.1 mL/min; 17.4 +/- 2.8 mL/min and 17.7 +/- 3.5 mL/min at 1-6 months; p<0.000). Despite the potentially confusing effect of comorbidity, the main clinical data improved. CONCLUSIONS: A flexible approach allowed development of DHD in approximately 11% of hemodialysis patients, with promising clinical results, despite frequent comorbidity.

Adult↗

PubMedDate not supplied

Teaching peritoneal dialysis in medical school: an Italian pilot experience.

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Clinical Competence↗