Medical Library

[Bad news in nephrology.]

The impact with a diagnosis of terminal chronic kidney failure produces a strong reaction in the patient, who feels confused, scared, angry and often expresses his scepticism about the physician\’s competence. It as been observed that the physician\’s attitude during his first contact with the patient determines the features of the patient\’s approach to the disease and its treatment. Respect, tact, empathy, support and information precision are essential to the establishment of a productive communication relationship resulting in a satisfying level of patients\’ awareness and compliance. A group of 80 patients was surveyed with a semi-structured interview aimed at evaluating physicians\’ communication strategies and patients\’ emotional experience. In order to improve the patients\’ life quality by making him an active part of every step of his treatment, is strongly recommended the adoption of a patient-centred communication pattern based on contact and positive unconditioned acceptance.

Seu S, Spina M, Marongiu F, Fresu A, Manca EM.

Servizio di Emodialisi, Arco dell\’Angelo, Casa di Cura Lay, Cagliari - Italy.

[Switch from Darbepoetin-alpha to Epoetin-alpha: cost and efficacy comparison for haemodialytic patients over one year follow-up in a single centre.]

Due to the increased emphasis on cost-containment, drugs must be proven not only to be safe and effective, but also to reduce costs, prior to be used in clinical practice. In the context of this saving policy, 12 clinically stable patients on hemodialysis who were administered darbepoetin-alpha (Aranesp(R)) (DARB) for at least 16 months in single weekly doses, were converted to EPO-alpha, administered 2-3 times per week. The initial dose of EPO-alpha was calculated on the basis of a dose-conversion ratio (DCR) of 200 IU EPO-alpha = 1 mcg DARB. The mean Hb value in the six months preceding the conversion was between 11 and 12 g/dL, with a monthly dose of DARB unchanged/ reduced during the last three months. During the last month of treatment with DARB, the mean Hb value of the cohort was 11.4+/-0.5 g/dL and the mean weekly dose per patient was 24g/12 mcg. After two months of EPO-alpha use, the mean Hb value dropped to 10.8+/-0.7 g/dL, with a mean monthly dose per patient of 5.667+/-2.229 IU, corresponding to a DCR of 234. In order to bring the Hb values back to above 11 g/dL, doses of EPO-alpha were progressively increased up to a maximum of 10.000+/-5.461 IU per patient, corresponding to a DCR of 414. The attempt to convert 12 hemodialysis patients treated with darbepoetin-alpha to an ESA with an apparent lower cost resulted in a worsening of the anemia of the patients after the conversion. Instead of leading to savings, the conversion actually increased expenditures.

Orazi E.

Struttura Semplice Emodialisi Extracorporea - CAL Dialisi di Peschiera Borromeo, A.O. di Melegnano, P.O. di Vizzolo Predabissi (Milano) - Italy.

[Dialysis and quality of life: identifies critical points for orientates to therapy choice.]

Living with a chronic disease is for the patient a \’\'disease experience\’\’ that also affects the psychosocial sphere and has a negative impact on perceived quality of life. To estimate the effect of dialysis on the perceived quality of life and to identify by means of a specific questionnaire the aspects that are compromised most. From our results it emerged that the examined patients had a sufficiently good total perception of quality of life, even though about 30% of the patients reported critical aspects related to daily life and, in some age groups, also related to dialysis method. This study confirms the importance of developing educational and supportive predialysis programs in order to identify and reduce the critical aspects.

Del Corso C, Caravello G, Betti MG, Ferretti S, Lunardi W, Tavolaro A, Capitanini A, Petrone I, Rossi A, Cerri A, Galati V, Marini M, Sardi T, Valenti I.

S.A. Nefrologia e Dialisi, ASL 3, Ospedale Civile, Pescia (Pistoia) - Italy.

[The sympathetic system and neuroendocrine hypertension.]

Sporadic pheochromocytoma is a rare tumor that should be taken into account in patients with hypertensive crisis, arrhythmias, and panic disorder. Familial pheochromocytoma is frequently found in subjects with von Hippel-Lindau disease, multiple endocrine neoplasia type II, neurofibromatosis, and SDHD gene mutations. The prevalence of sporadic pheochromocytoma is very low, approximately 0.05% among subjects with essential hypertension and even less in the general population. However, aggressive diagnostic intervention is recommended whenever a pheochromocytoma is suspected because the uncontrolled catecholamine release from the tumor can lead to serious and potentially lethal complications. Plasma free metanephrines have been shown to have high sensitivity and specificity in the biochemical diagnosis of sporadic and familial pheochromocytoma. Measurement of 24-hour urinary fractionated metanephrines may be an acceptable alternative in many patients. The current approach to the diagnostic localization of pheochromocytoma relies on computed tomography (CT), magnetic resonance imaging (MRI) and [123-I] and [131-I] MIBG scintigraphy. CT and MRI have very high sensitivity but low specificity, whereas MIBG scintigraphy has good specificity but its sensitivity is less than optimal, especially for the detection of metastases. In difficult cases, PET imaging appears to be promising.

Zuccala\’ A, Di Nicolo\’ P, Fiorenza S, Lifrieri F, Rapana\’ R.

U.O.C. di Nefrologia e Dialisi \’\'Laerte Poletti\’\', Ospedale \’\'S. Maria della Scaletta\’\', AUSL, Imola (BO) - Italy.

[Daily/nocturnal hemodialysis: only for the happy few or a real alternative for many?]

After the negative results of the HEMO study there is renewed interest in alternative, more \’\'physiological\’\’ dialysis schemes, such as short daily or nocturnal dialysis. Considerable experience has been acquired with short daily hemodialysis, especially in Italy and the Netherlands. Nocturnal daily hemodialysis is mostly performed in Canada, the USA and Australia. Long hemodialysis three times a week is used in Tassin, France. Many observational studies and the prospective controlled London Study have suggested improvements in many intermediate patient outcomes such as dialysis-related symptoms, blood pressure and volume control, phosphate control (only for nocturnal daily dialysis), nutritional status, and quality of life. These studies are, however, too small and underpowered to evince differences in the primary outcomes, mortality and morbidity. An International Registry of Daily Dialysis has been created to obtain further information, and the US National Institutes of Health have sponsored two large-scale trials to compare short and nocturnal daily dialysis with conventional schemes. Organizational problems, higher costs especially initially, and the unavailability of simpler dialysis machines are the main factors that hamper the widespread use of these new schemes. Long nocturnal hemodialysis either in hospital or at home, three times a week or every other night, appears overall the best arrangement and the most attractive solution at present. It provides significant advantages with a minimal increase in cost. It would be interesting if the Italian National Health Service would prioritize funding for these promising schemes of hemodialysis.

Sghirlanzoni MC, Mingardi G.

Unita\’ a Struttura Complessa di Nefrologia e Dialisi, Azienda Ospedaliera Ospedali Riuniti, Bergamo - Italy.

[Autosomal dominant polycystic kidney disease: from genes to cilium.]

Autosomal dominant polycystic kidney disease (ADPKD) is a quite frequent monogenic hereditary disease. The incidence has been reported to range between 1:400 and 1:1000 life births. The disease is caused by a mutation of the PKD1 gene in 85% of the cases and by a mutation of the PKD2 gene in the remaining 15%. The main characteristic of this condition is the development of renal cysts. Observations regarding various cystic kidney diseases sustained by mutations of different genes are steadily converging to a common point. This unifying element is the primary cilium. The cilium, which has long been considered a mere biological oddity, has lately become the focus of intense scientific attention because it may turn out to be the key to the understanding of cystic degeneration. The cilia can be regarded as sensors projecting out of the cell. In particular in the kidney they are located in an ideal place to capture information from the tubular lumen. One of the roles the cilia may play is the reception of chemical signals. An alternative hypothesis attributes to the cilia the role of mechanosensors capable of detecting variations of the urine flux in the tubular lumen. The cilium projects itself into the lumen where it can readily capture variations in the external environment and transmit them to the cell by as yet undefined pathways. This is the still largely unexplored frontier that will provide the elements needed to understand and treat renal cystic diseases.

Magistroni R, Furci L, Albertazzi A.

Divisione di Nefrologia, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Universita\’ degli Studi, Modena - Italy.

[Proteomics and the kidney: an innovative approach to the study of renal disease.]

In the post human genome era, several \’\'omics\’\’ fields are emerging. Proteomics has experienced a rapid growth in the recent past and has great potential for the future. Proteomic technologies are used with increasing frequency also in nephrology. The aim of this review is to examine the recent application of emerging proteomic technologies to the study of renal physiology and pathophysiology. We highlight the use in renal research of a number of available techniques including 2-dimensional gel electrophoresis, liquid chromatography/mass spectrometry, surface-enhanced laser desorption/ionization, and capillary electrophoresis/mass spectrometry. We examine the role, efficacy and diagnostic potential of the different proteomic approaches, focusing on current difficulties and potential solutions. The integrating role of bioinformatics and the need for standardized procedures for sample preservation and analysis and reporting of results are also discussed. Although the field is still in an embryonic stage, the knowledge gained up to now is important not only for a better understanding of renal physiology and pathophysiology, but also for the identification of disease markers and the development and follow-up of new therapies. This review gives an overview of proteomics, providing background information, outlining the scopes, highlighting the applications in nephrology, and reporting advantages and limitations.

Netti GS, Rocchetti MT, Papale M, Centra M, Centonze D, Di Paolo S, Ranieri E, Gesualdo L.

Centro di Medicina Molecolare, Dipartimento Interaziendale di Nefrologia, Dialisi e Trapianto (DIAN), Facolta\’ di Medicina e Chirurgia, Universita\’ degli Studi, Foggia and Centro di Ricerca Interdipartimentale \’\'Bioagromed\’\', Universita\’ degli Studi, Foggia - Italy.

[Stem cells and repair of kidney damage.]

In the adult kidney, different populations of progenitor cells (or stem cells) have been identified. These cells may represent a remnant of embryonic stem cells in the adult tissue, or populations of bone-marrow-derived stem cells homed within the kidney and modified by the local microenvironment. This modification may be the expression of a partial commitment or of different degrees of maturation. Resident stem cells may account for the growth of the organ during development, for the physiological cell turnover, and for the repair of kidney damage. In addition, stem cells derived from the bone marrow and migrated through the circulation to the site of the damage may contribute to tissue repair. Preliminary studies suggest that this regenerative potential of stem cells could be exploited for therapeutic purposes by administration of ex vivo expanded stem cell populations or by development of strategies aimed to expand and differentiate local stem cells.

Bussolati B, Camussi G.

Laboratorio di Fisiopatologia Renale e Vascolare, Centro Dipartimento di Medicina Interna, Interdipartimentale di Biotecnologie, Universita\’ degli Studi, Torino - Italy.

[Nocturnal hypoxemia and cardiovascular risk in dialysis.]

no abstract.

Tripepi GL.

CNR-IBIM, Epidemiologia Clinica del Rischio Cardiovascolare nelle Nefropatie Croniche e Unita\’ Operativa di Nefrologia, Dialisi e Trapianto, Azienda Ospedaliera \’\'Bianchi-Melacrino-Morelli\’\', Reggio Calabria - Italy.

[The APC\’s of the cell death.]

no abstract.

Torreggiani M.

Brookdale Departments of Geriatrics and Adult Development, Division of Experimental Diabetes and Aging Mount Sinai School of Medicine, New York - USA.