Nicola Panocchia

Anorexia and Serum Leptin Levels in Hemodialysis Patients

Background and Aims: Hyperleptinemia is a common feature in hemodialysis (HD) patients. However, the role of increased serum leptin levels in the pathogenesis of HD-related anorexia is still controversial. The purpose of the present prospective study was to ascertain whether hyperleptinemia is causally implicated in the pathogenesis of HD-related anorexia. Methods: We measured the serum leptin levels and the serum leptin/body mass index (BMI) ratio in 24 healthy subjects and in 49 end-stage renal disease patients on maintenance HD. HD patients were subdivided into anorexic (14/49, 28.5%) and non-anorexic (35/49, 71.5%) according to a questionnaire discriminating for the presence of anorexia-related symptoms. Results: Calorie (kcal/kg/day) and protein (g/ kg/day) intakes were significantly lower in anorexic than in non-anorexic patients (20.1 ± 1.1 vs. 27.9 ± 1.3, p = 0.004, and 0.82 ± 0.05 vs. 1.19 ± 0.05, p = 0.001, respectively). Accordingly, serum albumin, total lymphocyte count, mid-arm muscle circumference, and the protein equivalence of nitrogen appearance (PNA) were significantly lower in anorexic patients. The serum leptin concentration (ng/ml) was significantly higher in HD patients than in controls, in males (15.33 ± 3.4 vs. 3.7 ± 0.3, p = 0.003) and in females (42.3 ± 7.2 vs. 10.5 ± 1.3, p = 0.03). Similarly, serum leptin/BMI ratio was significantly higher in HD patients than in controls, in males (0.56 ± 0.1 vs. 0.16 ± 0.02, p = 0.0028) and in females (1.8 ± 0.2 vs. 0.4 ± 0.04, p < 0.0001). However, serum leptin levels were similar in anorexic and in non-anorexic patients, in males (15.3 ± 5.6 vs. 16.9 ± 4.2, p = 0.85) and in females (46.6 ± 12.9 vs. 47.4 ± 9.4, p = 0.96). No differences were observed between the 2 groups in the serum leptin/BMI ratio, in males (0.59 ± 0.2 vs. 0.58 ± 0.14, p = 0.92) and in females (1.5 ± 0.4 vs. 1.8 ± 0.3, p = 0.94). Similarly, no statistically significant differences in terms of serum leptin levels and leptin/BMI ratio were observed between patients with dietary energy intake of <30 or ≧30 kcal/kg/day and between those with a dietary protein intake of <1.2 or ≧1.2 g/kg/day. No significant correlations were found between serum leptin levels and PNA, albumin, cholesterol, total lymphocytes number, weight change, C-reactive protein, fibrinogen, ferritin, and complement. Conclusion: The present results indicate that mechanisms other than increases in serum leptin levels might be involved in the pathogenesis of HD-related anorexia.

PREGNANCY DURING CHRONIC HEMODIALYSIS: A SINGLE DIALYSIS-UNIT EXPERIENCE WITH FIVE CASES

Background: Pregnancy is uncommon in women with end-stage renal disease (ESRD) requiring chronic dialysis. An increasing number of successful pregnancies in women in hemodialytic treatment have been recently reported but few institutions experienced more than one or two cases of pregnancy. Methods: Between 1988–1998 five pregnancies in patients receiving hemodialysis were observed in our center. Medical records of these patients were reviewed. Results: At the conception the mean age was 27 years. One patient started dialysis after conception. All patients received bicarbonate dialysis. Three patients were dialyzed six times per week, the other two patients three-four times per week. The dry weight was increased progressively; on average of 1.2 ± 0.5 kg in the first trimester and of 0.5 kg per week since the second trimester. The predialysis BUN was maintained between 50–100 mg/dL (17.85–35,70 mmol/L) during the pregnancy. Four patients were treated with erythropoietin to maintain hematocrit between 30–35%. Erythropoietin related—complications were not observed. Polyhydramnios was observed in all cases. All deliveries occurred before term. The mean gestational age of infants was 28.6 ± 4 weeks. Four out of five pregnancies resulted in liveborn infants. Two infants had an Apgar score of zero. All neonates were of low birth weight (1431 ± 738 g) with percentile of birth weight in the normal range. No one was small for date. Conclusion: A successful pregnancy is possible in women on chronic dialysis. Prematurity occurs frequently as well as low weight birth leading to increased perinatal morbidity and mortality.

Switch from calcitriol to paricalcitol in secondary hyperparathyroidism of hemodialysis patients: Responsiveness is related to parathyroid gland size

Paricalcitol is more effective than calcitriol in hemodialysis patients (HD) with secondary hyperparathyroidism (SHPT), but it is not effective in some of them. We have investigated the relationship between paricalcitol responsiveness and parathyroid gland (PTG) size. Thirty HD with SHPT treated previously with calcitriol for at least 6 months were switched to paricalcitol (1:4 conversion ratio). Parathyroid gland number and size (maximum longitudinal diameter [MLD] of largest PTG) was measured by ultrasonography. Patients were divided into 2 groups: group A (MLD ≤9.0 mm [17 HD]); and group B (MLD >9.0 mm [13 HD]). They were defined responder if both the last 2 monthly determinations of inhibit parathyroid hormone (iPTH) were within the target (<300 pg/mL) according to National Kidney Foundation Kidney Disease Outcomes Quality Initiative recommendations. Twenty‐six and 20 HD completed 6‐month and 12‐month paricalcitol therapy, respectively. After 6 months of paricalcitol treatment, 23.5% HD of group A and 7.7% of group B were responders. At 12 months, 41.2 % of group A and 7.7% of group B were responders. Throughout paricalcitol therapy, serum calcium and phosphorus concentrations slightly increased in all HD but more significantly in group B. The baseline iPTH and MLD of the largest PTG were significantly correlated with final iPTH levels. Paricalcitol is more effective than calcitriol in SHPT, but the responsiveness to paricalcitol and hypercalcemia are related to PTG size. The measurement of MLD by ultrasonography may be useful for predicting responsiveness to paricalcitol, avoiding an unnecessary and expensive therapy.

The diagnostic boundary between autism spectrum disorder, intellectual developmental disorder and schizophrenia spectrum disorders

Purpose – During the last few years the prevalence of autism and Autism Spectrum Disorder (ASD) has increased greatly. A recurring issue is the overlap and boundaries between Intellectual Developmental Disorder (IDD), ASD and Schizophrenia Spectrum Disorders (SSD). In clinical practice with people with IDD, the alternative or adjunctive diagnosis of ASD or SSD is particularly challenging. The purpose of this paper is to define the boundaries and overlapping clinical characteristics of IDD, ASD and SSD; highlight the most relevant differences in clinical presentation; and provide a clinical framework within which to recognize the impact of IDD and ASD in the diagnosis of SSD. Design/methodology/approach – A systematic mapping of the international literature was conducted on the basis of the following questions: first, what are considered to be core and overlapping aspects of IDD, ASD and SSD; second, what are the main issues in clinical practice; and third, can key diagnostic flags be identified to assist ...

Mortality in hospitalized chronic kidney disease patients starting unplanned urgent haemodialysis

Data on the outcome of chronic kidney disease (CKD) patients who are hospitalized and start unplanned urgent haemodialysis (HD) are lacking. This prospective, longitudinal, observational study aimed to define the hospital mortality rate and associated factors in CKD patients who start unplanned urgent HD.

Intradialytic hypotension is associated with dialytic age in patients on chronic hemodialysis.

Abstract Objective: Intradialytic hypotension (IDH) is common in patients on chronic hemodialysis, but knowledge on determinants is still unclear. The present study aims at evaluating the association between IDH and dialytic age (DA) in patients on chronic hemodialysis. Methods: Between January 2012 and January 2013, 82 patients on chronic hemodialysis for at least 1 year were screened for inclusion in the present study. Of these, 14 were excluded because of advanced heart failure (n.9), history of alcohol/substance abuse (n.1), diagnosis of dementia (n.2), actual instability of clinical conditions requiring hospitalization (n.2). IDH was defined as a decrease in systolic blood pressure ≥20 mmHg or a decrease in mean arterial pressure (MAP) by 10 mmHg associated with clinical events and need for nursing interventions. The number of IDH episodes in 10 consecutive hemodialysis sessions was recorded for each patient. Linear and logistic regressions were adopted to assess the adjusted association between IDH and DA. Results: The mean DA was 92 ± 81. Eleven patients (16%) experienced IDH. DA was associated with IDH (OR = 1.01; 95% CI = 1.01–1.02; p = 0.048), after adjusting for potential confounders. DA was associated with the numbers of IDH events in the unadjusted model (B = 0.02; 95% CI = 0.01–0.03; p = 0.042), after adjusting for age and sex (B = 0.01; 95% CI = 0.01–0.03; p = 0.042) as well as in the multivariable model (B = 0.02; 95% CI = 0.01–0.05; p = 0.045). Conclusion: DA is associated with an increased probability of IDH and with increased number of IHD events. Studies are needed to understand the underlying factors of such an association.

Survey on advance care planning of Italian outpatients on chronic haemodialysis

Objectives The clinical practice guidelines published by the Renal Physicians Association (USA) recommend instituting advance care planning (ACP) for patients with end-stage renal disease. Studies on this issue are lacking in Italy. Our aim was to determine the attitudes of patients on ACP in our dialysis centre. Methods We performed a cross-sectional survey. We recruited patients on maintenance haemodialysis (HD) at Hemodialysis Center of Università Cattolica del Sacro Cuore, from 1 March 2014 to 31 March 2015. The only exclusion criterion was inability to give an informed consent. Patients completed a questionnaire concerning their treatment preferences in three hypothetical disease scenarios: persistent vegetative state, advanced dementia, severe terminal illness; for each patients, we also collected clinical, functional and socioeconomic data. Results Thirty-four HD outpatients completed the study questionnaire. The majority of respondents (85%) considered information about prognosis, health conditions and treatment options, including withdrawing dialysis, as very important and 94% of respondents considered treatment of uraemic/dialytic symptoms the most important issue. In the health scenarios provided, dialysis was the treatment least withheld. Dependence on instrumental activities of daily living (0.048) and higher Charlson Comorbidity Index scores (p=0.035) were associated with continuing dialysis in at least one scenario. Conclusions ACP should be tailored to patients’ value, culture and preferences. A significant proportion of patients, however, do not want to be involved in end of life decisions. Frail elderly patients, in particular, are not inclined to interrupt dialysis, despite poor quality of life or a poor prognosis.

Spatial distribution of kidney disease in the contaminated site of Taranto (Italy)

BACKGROUND Exposure to heavy metals has been associated with kidney disease. We investigated the spatial distribution of kidney disease in the industrially contaminated site of Taranto. METHODS Cases were subjects with a first hospital discharge diagnosis of kidney disease. Cases affected by specific comorbidities were excluded. Standardized Hospitalization Ratios (SHRs) were computed for low/high exposure area and for modeled spatial distribution of cadmium and fine particulate matter. RESULT Using the high/low exposure approach, in subjects aged 20-59 years residing in the high exposure area a significant excess of hospitalization was observed in males and a non-significant excess in females. No excesses were observed in subjects aged 60 years and over. The analysis by the modeling approach did not show a significant association with the greatest pollution impact area. CONCLUSION Due to the excesses of hospitalization observed in the high/low exposure approach, a continuing epidemiological surveillance of residents and occupational groups is warranted.

Buttonhole Technique: to try or not to try

Starting from the recent analysis about the buttonhole technique (BT) by Dr. Napoli (6), our study focuses on some uncertain issues of the results. In particular, the increased risk of infection and the low incidence of aneurysms associated with BT. If BT safety will be confirmed in future studies it might be chosen for patients who present a particular arteriovenous fistula (AVF) location and in order to reduce aneurysm formation.

Clinical Bioethics: Guideline on Initiation of and Withdrawal from Dialysis

The clinical issue of initiation of and withdrawal from dialysis for patients with chronic renal failure (CRF) is addressed evaluating for which patients the treatment is not indicated. Therefore, the initial question on the provision of dialytic procedure for all the patients who might obtain a benefit was alternated by an opposite problem: to understand, among the many candidates for dialysis, those who wouldn’t have a benefit. In fact, if the treatment is not able to offer the expected effectiveness, so configuring a medical futility or where the burdensomeness of the treatment (side effects, complications, etc.) exceed the benefits, it is ethically more appropriate not to start (or possibly withdraw) the treatment itself. Some scientific societies have edited specific guidelines. The article focuses on the last version of the Shared Decision Making in the Appropriate Initiation of and Withdrawal from Dialysis, Clinical Practice Guideline of the U.S. Renal Physician Association (RPA), that takes into account changes in epidemiology and clinical management of patients eligible for renal replacement treatment: mainly, increasingly advanced age, cardiovascular and metabolic disorders and comorbidity. The most compelling clinical issue is the identification of patients whose dialysis treatment is not beneficial in terms of survival and quality of health. Moreover, the RPA guidelines highlight the relevance of shared decision making as elective way for the physician-patient relationship. From the bioethics perspective, some lexical changes could reflect cultural changes: e.g., the term informed consent/refusal has been replaced by “information to the patient”, as well as “advance directive” by advance care planning. Some commentaries to RPA guidelines argue in favor of the reverse of some paradigms of North American bioethics: for example the overcoming of principle of autonomy towards a presumed restore of the principle of beneficence/ non-maleficence. In the appendix, a “Proposal for ethical guidelines for an appropriate indication for dialysis treatment” is offered to the debate. The document born from a common reflection and interaction between Hemodialysis Unit personnel of “Agostino Gemelli” Teaching Hospital (Rome, Italy) and clinical ethics consultations provided by ethicists of the Institute of Bioethics of the Universita Cattolica del Sacro Cuore (Rome, Italy) along the SINTEA Project (Integrated Service for Applied Bioethics) presented for the first time during a scientific meeting in 2010.