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The increasing technological effectiveness has undoubtedly produced an improvement in clinical parameters of dialysis patients, but this satisfactory therapeutic result did not follow an adequate improvement in mortality or in the perception of quality of life as per patients. Furthermore, dialysis treatment is often associated with "inapparent charges" that reduce the perception of well-being, independently of clinical changes. Thirty years ago, we carried out a national survey on inapparent charges, which represent frustrating aspects that negatively affect patients' perception of their quality of life. Thirty years later, it seemed important for us to repeat the survey to understand if Italian legislative remodeling have introduced changes in procedures and social aspects of dialysis, as preservation of quality of life is an important aspect of the replacement treatment., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

The SIN Workforce Working Group has carried out an initial demographic study project that highlights the situation of nephrological workforce in European and non-European countries, noting in particular the apparent discrepancies between the number of nephrologists in other health systems and in the Italian one. Italy seems to have the highest number of nephrologists per capita: in fact, the number of nephrologists has decreased in recent years due to the number of retirements far higher than the entry of new specialists. The project arises from the need to define the actual number of nephrologists in Italy in relation to the population and the epidemiology of chronic renal disease, taking into account the trends of ageing and feminization of our specialty. The tools used to collect data on the demographics of Italian nephrologists are a database for demographic data collection by presidents of SIN regional sections and a questionnaire for a survey to describe demography, workload, the adhesion to the discipline and the recruitment and retirement programs of the Italian nephrological community., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The complete digitalization of the health system is an objective that Italy, from 2014, is pursuing with great difficulty, spurred by the many European initiatives dedicated to it. Despite the social and cultural background seems to be clearly ready for an application of the renewal strategies, e-Health and m-Health are struggling to get off the ground throughout the territory. The main difficulties are find at local level and don't spare any medical discipline, nephrology included. The characteristics of the official websites belonging to the local health centers demonstrate it. Today, these institutions are still sparsely present on Social Media or in the Italian Smart Mobile Technology landscape. The article illustrates the main features of the phenomenon and calls for reflection on the necessity to accelerate the digital innovation of the communication with patients. This is a possible strategy for reducing chronicity through prevention, and, potentially, for decreasing health costs., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

This position paper of the study group "Conservative treatment of Chronic Kidney Disease-CKD" of the Italian Society of Nephrology addresses major practical, unresolved, issues related to the conservative treatment of chronic renal disease. Specifically, controversial topics from everyday clinical nephrology practice which cannot find a clear, definitive answer in the current literature or in nephrology guidelines are discussed. The paper reports the point of view of the study group. Concise and practical advice is given on several common issues: renal biopsy in diabetes; dual blockade of the renin-angiotensin-aldosterone system (RAAS); management of iron deficiency; low protein diet; dietary salt intake; bicarbonate supplementation; treatment of obesity; the choice of conservative therapy vs. dialysis. For each topic synthetic statements, guideline-style, are reported.

Up to 1968, clinical methodology was considered a central step in construction of Medical procedure. Later, after specialization or high specialization introduction, it totally disappeared. The results is the absence of any epistemological knowledge in the construction of diagnosis, based on two main theory: inductivism and hypothetico-deductivism. Both start from the point that diagnostic theory can be developed in close touch with experiment and observation. The inductive theory builds up the diagnosis on the multiple observations, while the deductive theory formulates the diagnosis from the bright idea which inspires the doctor who then has to check his theory by observation. The difference between two approaches to diagnosis is based on the tabula rasa of inductive physician and tabula plena of deductive physician. Without a methodology knowledge, the new doctors are lacking of proper correct approach to right diagnosis and therapy and rarely use academic tools to deepen it in clinical work. We consider many epistemology clinical aspects related to science and medical practice. In addition, we point out the attention to some cases on the basis of new inductive and deductive theories, in order to have respect for patients and doctors dignity.

Background: Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted acensusof the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to theyear 2014., Methods: An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit., Results: Renal and dialysis activity was performed by over 2718 physicians (45 pmp). The management of the acute renal failure was one of the most frequent activities in the public renal units (12,206 patients in ICU and 140.00 dialysis sessions). There were performed about 9000 AV fistulas and 1700 central vascular catheters insertions. In the census, there are a lot of data regarding organization, workforce and workload of the renal unit in Italy. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

Background: Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to the year 2014., Methods: An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit., Results: 615 renal units were identified. From these 615 units, 332 were public renal centres (of which 318 centres answered to the census) and 283 were private dialysis centres (of which 113 centres answered to the census). The results show 6 public renal units pmp. Renal biopsies were 4624 (81 pmp). The nephrology beds are about 41 pmp. There are 7.304 nurses working in HD wards, 1.692 in the nephrology wards and only 613 for outpatients clinics. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

Epidemiology of Acute Kidney Injury (AKI) has changed radically in the past 15 years: we have observed an exponential increase of cases with high mortality and residual disability, particularly in those patients who need dialysis treatment. Those who survive AKI have an increased risk of requiring dialysis after hospital discharge over the short term as well as long term. They have an increased risk of deteriorating residual kidney function and cardiovascular events as well as a shorter life expectancy. Given the severe prognosis, difficulties of treatment, high level of resources needed, increased workload and consequently costs, several aspects of AKI have not been sufficiently investigated. Any national register of AKI has not been developed and its absence has an impact on provisional strategies. Specific training should be planned beginning with University, which should include practical training in Intensive Care Units. A definition of the organizational characteristics and requirements for the care of AKI is needed. Treatment of AKI is not based exclusively on dialysis efficiency or technology, but also on professional skills, volume of activity, clinical experience, model of healthcare organizations, continuity of processes and medical activities to guarantee such as a closed-staff system. Progress in knowledge and technology has only partially modified the outcome and prognosis of AKI patients; consequently, new strategies based on increased awareness, on the implementation of professional skills, and on revision, definition and updating of resources for the organization of AKI management are needed and expected over the short term.

Unlabelled: The Italian Registry of Dialysis and Transplantation (RIDT) has recently resumed the collection of data of patients on RRT in Italy. Data were requested to Regional Registries for the years 2011-2013 and they contributed according to their possibilities. Eighteen Regions or autonomous Provinces provided data with various degrees of completeness and this made possible to bridge the gap between the current and the previous census (referring to 2010)., Results: Incidencedata were associated to a sample with a coverage of 77% of the national population (46/60 million inhabitants). Patients who started dialysis in these three years were, respectively, 168, 166 and 160 patients pmp. If we project this data to the national population is reasonable to think that 9500-10000 patients per year start the dialytic treatment., Prevalence: The prevalence of patients on dialysis in Italy range, in the 10 years of RIDT, between 750 and 825 patients pmp. Based on this we can reasonably estimate that in Italy there are 45-49000 dialysis patients. Incidence and prevalence vary widely in different regions. Mortalityon dialysis in Italy during the period 2011-2013 was on average 16.2 per 100 patient-years (95% CI: 16.1-16.7) with regional variation smaller than that observed in incidence and prevalence., Conclusions: In this paper, data analysis are presented in a direct and non comparative manner. However, it provides information on the status of the RRT in Italy and the temporal consistency of the data is a proof of their validity. Registry data were published in the official site of Italian Registry that can be reached through the website of SIN (www.sin-italy.org).

Background: Knowledge about mineral bone disorder (MBD) management in non-dialysis chronic kidney disease (ND-CKD) patients is scarce, although essential to identifying areas for therapeutic improvement., Methods: We prospectively evaluated current management of CKD-MBD in two visits, performed 6 months apart, in 727 prevalent ND-CKD stage 3b-5 patients from 19 nephrology clinics. Therapeutic inertia was defined as lack of treatment despite hyperphosphatemia and/or hypocalcemia, and/or hyperparathyroidism. The primary endpoint was the prevalence of achieved target for CKD-MBD parameters and related treatments (phosphate binders, vitamin D and calcium supplements). The secondary endpoint was the assessment of prevalence and clinical correlates of therapeutic inertia., Results: Over 65 % of patients did not reach parathormone (PTH) targets, while 15 and 19 % did not reach phosphate and calcium targets, respectively. The proportion of untreated patients decreased from stage 3b to 5 (at baseline, from 60 to 16 %, respectively). From baseline to the 6-month visit, the achievement of targets remained stable. Low protein diet was prescribed in 26 % of patients, phosphate binders in 17.3 % (calcium-based binders 15.5 %, aluminium binders 1.8 %), and vitamin D in 50.5 %. The overall prevalence of therapeutic inertia at the 6-month visit was 34.0 % (for hyperphosphatemia, 54.3 %). Compared to CKD stage 3, the likelihood of therapeutic inertia was 40 and 68 % lower at stage 4 and 5, respectively., Conclusions: PTH, calcium and phosphate targets were not reached in a significant proportion of patients. One-third of patients with at least one MBD parameter not-at-target remained untreated. Therapeutic inertia regarding CKD-MBD treatment may be a major barrier to optimizing the prevention and cure of CKD-MBD.

The escalation of the crisis between society and administration had a negative impact on public administration, as highlighted by criminal acts (bribery, extortion, abuse of power). Other consequences of this crisis have been the bad administration phenomena, such as delays in carrying out the practices, lack of attention to people's questions and failure to comply with working hours. These phenomena culminate in treating people without due respect and necessary kindness. In this context, the so-called applied ethics has developed, consisting of the construction of rules for moral behaviour, adapted to particular fields as well as to the public.

Chronic kidney disease is acknowledged as one of the most relevant disease for public health. Knowledge of epidemiology of CKD may allow public health interventions both for prevention and treatment in order to limit burden and management costs. Nefrodata is a multicentric, prospective, and observational study conducted in Italy, including patients with CKD followed in a specialist setting. The study uses a web-based data setting; it includes 1263 subjects with an estimate glomerular filtration rate (eGFR) less than 60 ml/min *1,73 sqm, followed in outpatient clinics in Italy. Patients' characteristics analysis evidences that old subjects (mean age of 70.3 13.4 years, 55% of them older than 70 years), with cardiovascular morbidity (50,6%) and diabetics (37%) have a high prevalence. With the reduction of residual renal function, prevalence of hyperphospatemia, metabolic acidosis, use of erythropoiesis-stimulating agents, Vitamin D, and diuretics increases. Also allopurinol and gastric-protective drugs are widely used. Fifty-four and eight % of patients with CKD stage 4 and 65.9% of patients with CKD stage 5 received indication on nutritional therapy.

Objective: The most recent literature has shown extensively that a low-protein diet in patients with chronic kidney disease (CKD) delays the natural progression of end-stage renal disease and the necessary treatment of chronic dialysis. The aim of this study was to estimate the cost-effectiveness of a very low-protein diet compared with a moderate low-protein diet., Design: Markov model., Setting: The study was conducted from the perspective of the Italian National Health Service., Subjects: Patients with CKD stages 4 and 5. Seven hundred and two patients were considered, and half were treated with a very low-protein diet and the other half with a moderate low-protein diet., Intervention: The Markov model estimates the costs and the quality-adjusted life years (QALYs) associated with a very low-protein diet versus a moderate low-protein diet for patients with CKD Stages 4 and 5. The transition probability was estimated on data from 7 studies, which determined the efficacy of very low-protein diets in delaying the need to start maintenance dialysis. Utilities and cost were estimated from literature review and projected for the lifespan considered in the model. The annual cost of dialysis per patient was approximately €34,072. The cost of a very low-protein diet was €1,440 per patient per year in the Lazio region (conservative assumptions). Probabilistic and deterministic sensitivity analyses were performed., Main Outcome Measure: QALY, cost of treatment, incremental cost-effectiveness ratio., Results: The model estimates that a very low-protein diet should be more effective. Dietary treatment improved 0.09 QALYs after 2 years, 0.16 after 3 years, 0.36 after 5 years, and up to 0.93 incremental QALYs after the first 10 years. After 2 years, the model estimated increment cost in favor of the most restrictive dietary treatment of €826, €2,146, €5,203, and €10,375 for 2, 3, 5, and 10 years of follow-up respectively., Conclusions: The results of these simulations indicate that the treatment of CKD patients with a very low-protein diet is cost-effective relative to a moderate low-protein diet in an Italian setting. Further studies should test this model in other countries with different dialysis costs and dietary support., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Nowadays a large amount of medical data are available, although they are not always homogeneous, they arise from different backgrounds and are used for different purposes. The aggregation of these data could give huge boost to the epidemiology and, in particular, to nephrology. In many parts of Italy there is the aim to reorganize the hospital health care, as well as the territorial setting. In this framework, the role of nephrology is evaluated without data to support the ongoing decisions, therefore the linkage among the data stored in the administrative and clinical databases of the Local Health Unit could contribute to the planning of nephrological (but not only) activities, in order to ensure the best cost-effectiveness possible for each different reality.

New media tools such as web 2.0 are increasingly being used in the medical field. RSS feeds, podcasts, blogs, wikis, online social networks and social media have all been proposed as innovative tools for the education and updating of clinicians, nurses, other health workers and medical students because of their ease of access and widespread use. Nephrology is one of the medical fields where these technologies have been successfully applied. Medical journals such as the American Journal Kidney Diseases and the Journal of the American Society of Nephrology, and medical societies such as the American Society of Nephrology, are all using these new and powerful communication tools. In addition, blogs and social networks have been developed to allow physicians to distribute, share and comment medical material concerning issues related to nephrology and kidney disease, including images, videos, slides, scientific abstracts and clinical trials updates. This review provides background information on the evolution of both web 2.0 and the social media and describes some of the most interesting applications of web 2.0 and its correlated tools in the field of nephrology.

Over the last years in the industrialized countries there have been many changes in the number and characteristics of patients starting renal replacement therapy. This review reports the changes that took place in Italy, analyzing the data from the Italian Registry of Dialysis and Transplantation (RIDT), which collects information from all Italian regions according to common inclusion and coding parameters. The years between 1999 and 2009 were analyzed for the calculation of the average and median age of incident patients, the percent distribution of the different diseases necessitating dialysis, and the mortality after one year. Patients who underwent a kidney transplant as the first event were not included in the analysis. The incidence of uremia in Italy showed a constant increase from 1999 (131 pmp) to 2009 (160 pmp), mainly due to an increase in patients aged over 70 years. In fact, in recent years about 50% of the patients who started renal replacement therapy were aged over 72, 25% were older than 78 years, and only 25% were younger than 60 years. According to the Italian epidemiological data, the percentage of patients with diabetic nephropathy or diabetes as comorbidity has risen steadily (from 19% in 1999 to 27% in 2009). However, in spite of the progressive increase in the two main risk factors for survival (older age and diabetes), the mortality after one year of renal replacement therapy did not show a significant rise from 1999 to 2009.

Background: Relative survival, a methodology previously used in epidemiologic studies of cancer, compares the observed survival of a patient cohort with expected survival derived from general population life tables. We examined relative survival in patients treated by long-term dialysis in the Italian Dialysis and Transplantation Registry in order to determine the prognosis of dialysis patients., Study Design: Cohort study drawn from a registry., Setting & Participants: Patients enrolled in the Italian Dialysis and Transplantation Registry., Factors: Sex, age, primary kidney disease, renal replacement therapy modality, and main comorbid conditions., Outcomes: Death from any cause., Measurements: Relative survival ratio (the ratio of observed survival in the population of interest to the survival expected given the age- and period-specific mortality of the general population) and excess mortality rate (difference between observed and expected mortality rates)., Results: In January 2000 to December 2008, a total of 27,642 patients were included. The 5-year relative survival estimate was 55.6% (95% CI, 54.7%-56.5%). The excess mortality rate showed a peak at 3 months (21 deaths/100 patient-years), then decreased, becoming constant from the end of year 1 to year 8, with leveling off at about 10 deaths/100 patient-years. Older age, systemic diseases, and diabetes showed the strongest association with excess mortality. Peritoneal dialysis was associated with a lower relative excess risk in only the first year of treatment., Limitations: The patient cohort comprises about half the Italian patients beginning dialysis therapy in the period., Conclusions: This study highlights the applicability of relative survival methods in dialysis patients. This measure allows estimation of disease prognosis and severity comparisons among chronic diseases. The excess mortality rate appears to be a more sensitive and informative measure than the simple proportion of survivors., (Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Albuminuria is a powerful predictor of renal and cardiovascular outcomes in type 2 diabetes and a good indicator of the evolution of renal disease. Our aim was to obtain information concerning the identification of albuminuria as well as the utilization of antihypertensive, lipid-lowering and antiplatelet drugs in patients with diabetes., Methods: Subjects were enrolled from individuals registered with 3 Italian local health units by querying the drugs reimbursable, hospital laboratory investigation and hospital discharge databases. The determination of albumin to creatinine ratio (ACR) throughout 2007 and 2008 was defined as the index date. Patients who received at least 2 prescriptions of hypoglycemic drugs in the 12 months before the index date were classified as diabetics. We looked also for prescriptions of antihypertensive, lipid-lowering and antiplatelet drugs., Results: Among a population of 701,133 subjects, we identified 29,350 patients with diabetes (4.2% of the cohort). ACR had been determined in 5,644 diabetic subjects (19.2% of that cohort). The prevalence of determination of ACR in nontreated subjects was 16.0%, while in treated subjects, it ranged from 13.6% to 34.9% according to different schedules of treatment. Drugs acting on the renin-angiotensin system were prescribed in more then 80% of diabetics. The ratio of angiotensin receptor blockers to angiotensin-converting enzyme inhibitors regimen was 0.64 in subjects without determination of ACR, 0.88 in subjects with normal albuminuria, 1.02 in subjects with microalbuminuria and 1.43 in subjects with macroalbuminuria., Conclusions: Our methodology can easily be applied to obtain an epidemiological view of albuminuria and pharmacological treatments of diabetics in a general population.

This paper reports the analysis of the second part of the data obtained from the second SIN census and illustrates the management model of the Italian dialysis centers, highlighting its strengths but also its limits. The census was carried out between March and December 2008 with a webbased survey using fillable PDF forms. The survey was validated by comparing the data with those sent to the Italian Dialysis and Transplant Register (Registro Italiano di Dialisi e Trapianti, RIDT) and hence it refers to December 31, 2008, the date of the last RIDT report. Forty-two percent of dialysis centers, which altogether take care of 50% of Italian dialysis patients, participated in the census. The participation percentage was very variable among Italian regions (from 5% to 100% of dialysis centers). By excluding the three regions with a participation rate below 10%, the survey reached a participation rate of 68% of all Italian dialysis centers and is therefore sufficient to give an estimate of the Italian dialysis situation. However, because of this variability it was not possible to compare regional situations, and the data were evaluated only by analyzing the ''complex'' and ''simple'' dialysis centers separately. The state of affairs of dialysis in Italy on the whole proved to be complicated. It is striking, for example, that 15% of the ''complex'' dialysis centers do not have their own hospital beds and some of them lack traceability programs. Noteworthy are also the increasing use of central venous catheters and the number of patients that need an ambulance to get to the dialysis center. Despite its limits due to the reduced participation in the census, this work offers a fair description of the state of affairs of dialysis in Italy, where there is certainly space for qualitative improvement. First of all, however, every effort should be made to implement and improve the use of the existing structures and to standardize protocols and behaviors in all Italian dialysis centers.

This paper reports on a first analysis of data of the second survey promoted by the Italian Society of Nephrology (SIN), with particular regard to data referring to the nephrologist's workload. The survey was carried out through a Web-based questionnaire that participants could fill in online between March and December 2010. The data were validated against those of the Italian Dialysis and Transplant Registry (RIDT) and therefore refer to 31 December 2008, the date of the last RIDT report. Accurate completion of the questionnaires and reminders were monitored by the presidents of the regional sections of the SIN and the regional registries' chairpersons under the coordination of four area managers and a census committee. The response to the survey represented 42% of all nephrology centers, treating about 50% of all dialysis patients in Italy. The response percentage varied widely among regions (from 5% to 100% of the centers). After exclusion of the three regions with responses below 10%, it reached 68%, which was sufficient to give an idea of the state of nephrology in Italy. However, due to this wide variability, it was not possible to make an overall comparison of the regional situations, hence data for complex and simple structures were assessed separately. Despite the limits due to the incomplete participation in the survey, this article provides a clear description of the state of nephrology in Italy. The results confirm the hypothesis presented in the work of Bocconi Cergas, namely that the nephrology market is broader than nephrologists are able to control. The work of the nephrologist, which still seems to be focused mainly on dialysis in its various forms, should be directed more towards the development of methods for early detection of kidney disease and close follow-up. The ultimate aim is the early diagnosis of kidney disease and hence prevention of its complications, so that the focus no longer needs to be on ESKD treatment systems.

Objective: Weight gain with oedema development is a complication of major surgical procedures with an incidence as high as 40%. Fluid retention is not always clinically evident and it is reported despite fluid-restriction regime. The causes are several and not totally clear. We performed a prospective study to assess the amount of fluid accumulation and redistribution observed after major thoracic surgery., Methods: In 49 patients submitted to lobectomy with systematic lymph node dissection for lung cancer, we measured preoperatively and on the postoperative days 1, 2, 4 and 7, body weight, fluid balance, brain natriuretic peptide (BNP) and bioimpedance analysis (BIA)-derived parameters resistance (R) and reactance (X(c))., Results: The postoperative course was characterised by significant changes. Mean increase in body weight was 2.7 kg ((1.9-3.4); p<0.001) on postoperative day 2. Most of the patients had a negative basal fluid balance (-244 ml (-520 to -50)), whereas, on postoperative day 2, we observed a positive and significant change (+968 ml (646-1456), p<0.001)). Total body R and X(c) fell on the first day (p<0.001), anticipating the changes in weight and fluid balance. BNP increased on day 1, immediately after surgery, and remained significantly above basal values for the entire observation period (p<0.001), in the absence of clinical signs of heart failure., Conclusion: The three methods used consistently showed a significant fluid retention over the course of the study. BIA was an easy, reproducible and non-invasive method for the estimation and early detection of fluid retention. Increase in BNP may be related to the systemic reaction to stress and to the decreased pulmonary vascular bed. We found no correlation between fluid retention and length of anaesthesia, sex, age, blood loss and body mass index. The clinical and prognostic implication of weight gain may be relevant to patient's health., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Advanced glycation end-products (AGEs) are proposed to influence inflammatory pathways and cardiovascular risk in chronic kidney disease (CKD). Dietary AGEs are believed to sustain circulating levels and toxicity in this condition., Design and Patients: We investigated this aspect in a cross-sectional pilot study measuring levels of the AGE marker carboxymethyl lysine (CML) and fluorescent AGEs in the blood of pre-dialysis patients with CKD and hemodialysis (HD) patients (n = 10 each), and in a group of matched healthy controls (Ctr)., Methods: Plasma CML was measured by immuno-dot blot and fluorescent AGEs were determined by high-performance liquid chromatography (HPLC) analysis measuring the fluorescence of the cross-link pentosidine. The dietary intake of CML was assessed by dietary recall to trace total AGE intake in patients with CKD and the Ctr group. All the subjects included in the study were assessed for dietary intake while maintaining their usual diet. Main exclusion criteria for patients with CKD and HD were severe protein-caloric malnutrition and inflammation (measured by high sensitivity C-reactive protein and interleukin-6 levels)., Results: Plasma CML, as well as free and protein-bound fluorescent AGEs, significantly increased in CKD and even more in HD patients than that of the Ctr group. In patients with CKD, the average dietary intake of CML was less than half than that of the Ctr group (6 vs. 13 MU/day) and the lowered protein intake adopted spontaneously by these patients appear to explain this finding., Conclusions: The results show that the intake of CML does not affect circulating levels of this as well as of other AGEs, in well nourished predialysis CKD patients., (Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

The care provided by a nephrologist is fundamental because the nephrologist is able to prevent, recognize and treat the many and complex factors of comorbidity inherent in chronic kidney disease at its various stages. The nephrologist also has the important task of delaying the start of dialysis for as long as possible. Delaying dialysis slightly, even just one year for each patient, will have ethical, social and economic advantages that should be duly weighed and carefully evaluated when adopting organizational models of care involving nephrology. The nephrologist bases his work on the clinical competence acquired and maintained through appropriate training programs based on CME courses and, above all, daily clinical practice that, in order to be truly educational, must reach a sufficient volume of activity to guarantee the best possible outcome to the patient.

Background: Chronic kidney disease (CKD) is an emerging worldwide problem. The lack of attention paid to kidney disease is well known and has been described in previous publications. However, little is known about the magnitude of the problem in highly specialized hospitals where serum creatinine values are used to estimate GFR values., Methods: We performed a cross-sectional evaluation of hospitalized adult patients who were admitted to the medical or surgical department of Santa Maria della Misericordia Hospital in 2007. Information regarding admissions was derived from a database. Our goal was to assess the prevalence of CKD (defined as an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2) and detection of CKD using diagnostic codes (Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]). To reduce the impact of acute renal failure on the study, the last eGFR obtained during hospitalization was the value used for analysis, and intensive care and nephrology unit admissions were excluded. We also excluded patients who had ICD-9-CM codes for renal replacement therapy, acute renal failure, and contrast administration listed as discharge diagnoses., Results: Of the 18,412 patients included in the study, 4,748 (25.8%) had reduced eGFRs, falling into the category of Kidney Disease Outcomes Quality Initiative (KDOQI) stage 3 (or higher) CKD. However, the diagnosis of CKD was only reported in 19% of these patients (904/4,748). It is therefore evident that there was a "gray area" corresponding to stage 3 CKD (eGFR 30-59 ml/min), in which most CKD diagnoses are missed. The ICD-9 code sensitivity for detecting CKD was significantly higher in patients with diabetes, hypertension, and cardiovascular disease (26.8%, 22.2%, and 23.7%, respectively) than in subjects without diabetes, hypertension, or cardiovascular disease (p < 0.001), but these values are low when the widely described relationship between such comorbidities and CKD is considered., Conclusion: Although CKD was common in this patient population at a large inpatient regional hospital, the low rates of CKD detection emphasize the primary role nephrologists must play in continued medical education, and the need for ongoing efforts to train physicians (particularly primary care providers) regarding eGFR interpretation and systematic screening for CKD in high-risk patients (i.e., the elderly, diabetics, hypertensives, and patients with CV disease).

This is the second part of a document describing a voluntary certification process based on Joint Commission International (JCI) criteria developed by the Italian Society of Nephrology (SIN) and JCI representatives. In the first part we discussed standards for clinical care delivery and performance measurements related to chronic kidney disease care. Herein (Part II), we complete the description of Performace measurements and CKD care by describing issues related the management and clinical information management.

Chronic kidney diseases (CKD) has now emerged as a public health priority, and there is an increasing demand by patients and health care organisations that the quality of care delivered by renal units to CKD patients be systematically monitored and evaluated. The Italian Society of Nephrology (SIN) has started an initiative aimed at promoting a quality certification process specifically focused on CKD. To this end, SIN started a collaboration with an independent Italian company which is a partner of Joint Commission International (JCI), a nonprofit international organisation dedicated to the promotion of quality improvement and safety of health services. As a result of this collaboration, a document describing a voluntary certification process developed based on JCI criteria was produced by SIN. This document comprises 2 parts. Herein (Part I) we deal with standards for clinical care delivery and performance measurements related to CKD care. Programme management and clinical information management will be presented in a separate manuscript (Part II).

Several prospective studies and meta-analyses including the recent Cochrane meta-analysis have demonstrated that reducing the protein content in the diet delays renal death and the start of dialysis in patients with chronic kidney disease (CKD). Reducing the dietary protein intake offers other benefits such as lowering accumulation of uremic toxins and circulating phosphates and improving symptoms and metabolic derangements. Following the publication of the Cochrane meta-analysis, some of the most renowned experts in Italy on dietary therapy in the CKD patient established a working group within the Italian Society of Nephrology (SIN), the ''Nephrontieres'' project. The current supplement of GIN presents the views of the members of the ''Nephrontieres'' group on a range of issues related to dietary therapy in CKD. A CME program for Italian nephrologists also originated from the collaborative work of the group.

Direct evaluation of the compliance with nutritional therapy is possible only in clinical trials while indirect methods such as self-reporting and interviews are used in clinical practice. Dietary history is the best method to evaluate nutritional habits in clinical practice; the same holds true for the compliance with low-protein diets in patients with chronic kidney disease. Other indexes to assess dietary compliance should be simple and easy to use in the clinical practice. Some of such functional and biological markers are blood urea nitrogen and serum phosphate levels (indirect markers of dietary intake), weight and body mass index (indirect markers of energy intake), and daily urinary excretion of nitrogen and sodium (indirect markers of protein and salt intake). The compliance with a low-protein diet in patients with chronic kidney disease is strongly influenced by psychosocial factors (e.g., satisfaction and comprehension), and thus by the supporting role of the physician and the dietitian, but also by the level of renal function and food characteristics. It must be pointed out that even a protein intake reduction of 0.2 g/kg/day improves blood urea nitrogen, phosphate levels, and acidosis.

The Italian research institute CENSIS recently estimated that the total monetary cost of dialysis in Italy reached almost 2,700 billion old lira (about 1.4 billion euros), with more than a quarter of that as social costs largely borne by families. The yearly cost in Italy for acetate and bicarbonate dialysis has been estimated at Euro 35,000 per patient and is steadily rising. Delaying renal death and start of dialysis by an average of two years is one of the most relevant ''monetary'' benefits of low-protein diets, even more so when considering that about half of all elderly patients starting dialytic treatment will die within three years. Reduced intake of phosphorus is another benefit of low-protein therapies that is associated with substantial monetary savings, thanks to a reduced need for phosphate-binding agents. Highly palatable preparations of low-protein content are already available, and are probably already self-paying if the savings from reduced prescription of phosphate binders are accounted for.

In recent years, evidence-based medicine (EBM) has acquired its own dignity and cultural identity, and increasing importance. EBM helps doctors understand that the uncertainties of medicine must be analyzed quantitatively in order to rationalize and systematize the information gathered from clinical observation; on the other hand, it provides them with suitable instruments to estimate the performance of diagnostic tests and the efficacy of drugs. One of the main merits of EBM has been the progressive spread of randomized controlled trials as the gold standard for evaluating the effectiveness of treatments. EBM's primary objectives can be summarized by the following points: 1) To transform the physicians' need for information into questions that may be answered (ie, formulate the questions); 2) To find in an as efficient way as possible the best evidence to answer these questions; 3) To critically evaluate the evidence obtained (ie, assign a weight to it) in order to determine its validity (ie, its approximation to the truth) and its usefulness (ie, its concrete clinical applicability); 4) To introduce into clinical practice the conclusions drawn from the results; 5) To estimate individual physicians' performance (ie, one's own conduct and efficiency). EBM's advantages are not only that physicians have acquired a method to search for the right evidence and to apply diagnostic and therapeutic procedures, but, more importantly, that it has provided them with the only tool for true quality improvement, namely the critical appraisal of their own work. Unfortunately, the latter is too often based on a different type of EBM: Evidence-Based Medicine.

In the last few years the Italian Society of Nephrology has addressed many technical-scientific and management aspects to better patient satisfaction. Project No. 1 of the 2004-2006 programme on 'Quality and Accreditation of National Renal Units' focuses on four essential points. The first is the questionnaire mailed to all the Presidents and Regional Delegates on the relationship between Nephrology units, Local Government Health-System and the Regional Healthcare Agency. The results evidence that the 'political' decision-making power of nephrologists decreases in the absence of a national strategy. The second point, in collaboration with the National Census Group, includes the quality analysis and the standardization of resources (human and structural) and management of the Renal Units. The third point is based on 'Educational Courses for Quality and Accreditation' held in Rome (3-5 October 2005: L'Accreditamento all'Eccellenza dell'Unita' Operativa di Nefrologia, Dialisi e Trapianto; 17-19 October 2005: Il Manuale di Accreditamento della Specialità di Nefrologia). The courses aim at training members responsible for each region to hold courses in their specific region to create a network including each single Renal Unit to create an acceptable homogenous language on the models of analysis and on the correct use of 'The Guide for Excellence Accreditation'. The fourth point concerns both the on-line Guide for Excellence Accreditation and 'Peer Review Accreditation' and the NEQUASY (Nephrology Quality System) project. The manual must be 'user friendly' allowing each Centre to self-evaluate using national and regional standards.

The Italian Society of Nephrology (SIN) promoted a national survey in order to collect detailed information from all Italian renal and dialysis units. This is the second paper, following the first one which focused on three northwestern regions, aim-ing to present the results of the survey. In this paper, data from the central regions (Abruzzo, Lazio, Marche, Molise and Umbria) are reported. The most relevant findings in the five regions were: A) epidemiology--prevalence of dialysis patients = 742, 781, 731, 814, 768 per million population (pmp); prevalence of transplanted patients = 162, 153, 296, 134, 304 pmp; incidence of dialysis patients = 175, 179, 184, 143, 162; gross mortality of dialysis patients = 12.3, 11.8, 15.9, 13.4, 14.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 90, 87, 82, 94, 80%, central venous catheter = 7, 10, 15, 4, 17%; vascular graft = 3, 3 ,3, 2, 3%. B) Structural resources--number of hospital beds = 52, 43, 39, 62, 44; dialysis places = 205, 260, 203, 301, 226. C) Personal resources--renal physicians = 50, 78, 47, 53, 47 pmp; renal nurses = 162, 172, 180, 224, 245 pmp; each renal physician takes care of 15, 10, 16, 15, 17 dialysis patients and each renal nurse cares of 4.6, 4.6, 4.1, 3.6, 3.1 dialysis patients. D) Activity--admission to hospital= 2334, 1689, 2652, 1255, 1377 pmp; renal biopsies = 59, 84, 97, 19, 80 pmp. Despite the differences we find among the regions, most indexes are similar and show a satisfactory level of renal care provided in the central regions examined.

As managed care relevance is growing, several old issues related to personal institutional responsibility are increasing among practitioners. Therefore, as a professional figure a nurse bases his/her job on a mix of personal knowledge and skills along with training, and he/she is responsible for giving advice in line with professional care standards. In addition, he/she is in charge of the treatment pattern agreed with the patient. However, nursing is a much more complex job, which leads professional figures facing the controversial issue of combining institutional responsibility and nursing professional tasks and duties daily. As far as nursing institutional responsibility is concerned, different view points or approaches can be applied to investigate it. The most common one is the legal approach, yet this is not the most appropriate one. Therefore, our professional background is mainly based on a management prospective rather than a legal one; dealing with the issue legally would lead, essentially, to a summary of laws and regulations without any kind of argumentative discussion. Consequently, this study aimed to analyze nurses' institutional responsibility by approaching the issue from an innovative human resources management prospective; therefore, defining the gap between nursing institutional responsibility and its tasks.

Continuing medical education is an essential element of state-of-the-art medical practice. Continuing medical education as structured today in most countries, must be able to guarantee the quality of continuing medical education and its independence. There should, therefore, be an independent professional body at national level responsible for assessing and guaranteeing both quality and independence. This body will also have the power to oversee the participation of medical specialists in continuing medical education. A system of credits should was developed to express the professional value of continuing medical education activities. Each activity is credited with a certain score, which can be awarded to the participating specialist. Continuing medical education should remain an ethical obligation subject to the disciplinary authority of the profession itself. Continuing medical education should be both an individual and also a collective obligation of the profession; in order to promote and make it effective, each member state must provide the means of making continuing medical education available to all physicians. For the above reason the CME is a strategic way to improve the quality of the health system. In Italy new way to obtain CME credits are going to be issue in the near future.

Background: Hypertension and left ventricular hypertrophy (LVH) are present in the majority of patients undergoing haemodialysis (HD). These two pathologies persist after dialysis onset, and pharmacological therapy is often required for adequate control of blood pressure (BP). Although fluid overload is a determinant of hypertension, clinical assessment of this parameter remains difficult and unsatisfactory. Bioimpedance analysis (BIA) spectroscopy and the relative determination of extracellular water (ECW%) may provide a simple and inexpensive tool for investigating fluid overload. We studied 110 patients on thrice-weekly HD to determine whether ECW body content correlates with hypertension and LVH in this patient population., Methods: Hypertension was determined according to the WHO criteria (office BP >/= 140/90 and/or the use of antihypertensive therapy). Twenty-four hour BP monitoring and echocardiography were performed on midweek inter-HD days. Blood chemistries, dialysis dose (spKt/V) and bioimpedance were analysed on midweek HD days., Results: Hypertension was present in 74.5% of patients. There were no differences for age, spKt/V, haemoglobin, serum creatinine and residual renal function between normotensive and hypertensive patients. Twenty-four hour systolic BP (SBP), 24 h diastolic BP and 24 h pulse pressure were higher in hypertensive patients, in spite of antihypertensive therapy. LVH was present in 61.8% of patients. BIA revealed that ECW% was increased in LVH+ patients (LVH+ = 47.5 +/- 7.9%, LVH- = 42.4 +/- 6.2%, P = 0.01) and in hypertensive patients compared with normotensives (46.5 +/- 7.7% vs 43 +/- 7.2%, P = 0.02). Dry body weights and inter-HD body weight increases did not differ between hypertensive and normotensive patients nor between patients with or without LVH. ECW was correlated with SBP (r = 0.35, P < 0.01) and with left ventricular mass index (LVMi(g/sqm)) (r = 0.49, P < 0.001). A stepwise multiple linear regression model revealed that LVMi(g/sqm) was significantly correlated with ECW%, SBP and male gender (r = 0.65, P < 0.001)., Conclusions: LVH and hypertension are present in a majority of HD patients and they are closely correlated with one another. We found associations between fluid load, measured by BIA and expressed as ECW, and BP and LVM.

Like many specialized branches of medicine, the future of nephrology will be entrusted to organizational models that are able to withstand the impact of both the new and increasing demand for assistance and the rationalization of resources. Therefore, it is necessary to clearly understand that the model must integrate and unify many aspects that regulate the activities in the health care service. Budget means "who does what and with material and what human resources" with respect to the constraints imposed by the decisions of the controlling entities, and it is mainly a system of planning and control. Management control utilizes a combined and coordinated synthesis of various company techniques including an auditing system, analytical accounting (or per cents of cost), a reporting system able to change the data gathered into measures of syntheses that can be used to carry out sound evaluations. The health system needs a type of organization--typical of professional organizations--that is an absolute prerogative of the technical/professional component which is the only one able to discern, understand and propose new diagnostic and therapeutic trends and approaches. At the end an evaluation of quality system is depicted. ISO 9004 norms, for example, provide principles on which an organization must be based, in order to reach high levels of quality and that must be used by the top management to lead the organization towards improved performance.