bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Zinc Supplementation on the Immune System and on Antibody Response to Multivalent Influenza Vaccine in Hemodialysis Patients
Authors: TüRK S. , Bozfakioglu S. , Ecder S.T. , Kahraman T. , GüREL N. , Erkoç R. , Aysuna N. , Türkmen A. , Bekiroglu N. , Ark E.
Published: March 2018

The depression of the immune system in chronic uremia is a well-known phenomenon but the role of serum zinc (Zn) levels on both cell-mediated and humoral immunity is still controversial. The aim of this study was to investigate the effect of Zn supplementation on the immune system and on antibody response to multivalent influenza vaccine (MIV) in hemodialysis patients (HP).

Twenty-six HP and 11 healthy subjects (HS) were vaccinated with MIV. Hemodialysis patients were randomly divided into two groups. Group 1 (13 HP) was supplemented with 120 mg ZnS04 after each dialysis session. Group II (13 HP) and Grouip III (11 HS) were given placebo. In all cases, the serum Zn levels, CD3, CD4, CD8, CD19, HLA-DR+ cell percentages, CD4/CD8 ratio and CD3+HLA-DR+ cell percentages were determined before and 30 days after vaccination. Antibody levels to subgroups of MIV were also measured.

All the baseline parameters studied were not statistically different between Group I and II. However, there was a significant difference between the basal parameters of Group III and the other two groups, except for CD3 and CD4 cell percentages.

Serum Zn, CD19 cell percentage and antibody levels to MIV subgroups were significantly increased in Group I at the end of the first month of the study (p<0.01, p<0.05, p<0.001, p<0.001, and p<0.01, respectively), but the other parameters showed no significant changes. The only significant change observed in Groups II and III was an increase in antibody levels to MIV subgroups one month after vaccination. Antibody levels to MIV subgroups, were not statistically different between Groups I and II, but in Group III they were strikingly higher than those of HP (p<0.001).

These results led us to conclude that Zn supplementation could not restore the immune parameters and enhance antibody response to MIV in HP.
Ex Vivo Testing of Heparin-Coated Extracorporeal Circuits: Bovine Experiments
Authors: Weerwind P.W. , Van Der Veen F.H. , Lindhout T. , De Jong D.S. , Cahalan P.T.
Published: March 2018

In this study the intrinsic thrombogenicity of the extracorporeal circuits and the benefit of heparin-bonded circuits in an extracorporeal life support system without full systemic heparinization and with minimal interference of the so called material-independent factors was tested in four calves. In two circuits (group A) all blood-contacting surfaces were coated with end-point-attached heparin and the other two were non-coated (group B). Under standardized conditions the calves were perfused at a blood flow rate of 2 L/min. After only one bolus injection of heparin (250 IU/kg body weight) before cannulation, plasma heparin activity rapidly decreased in both groups: half life of about 55 minutes. This decrease of the heparin activity was accompanied by a fall of the activated clotting time (ACT) level to baseline values. The experiments using a heparin-coated circuit, had a runtime of more than 360 minutes, whereas the experiments using a non-coated circuit had to be terminated after a runtime of 255 minutes, because massive fibrin formation was noticed in the circuit. This formation was accompanied by a rapid increase in the line pressure, measured just before the inlet of the oxygenator. The macroscopic inspections after terminating the experiments and rinsing the circuit showed a clean circuit in group A. The fibrinopeptide A (FPA) level increased faster during perfusion with the non-coated circuit than in the heparin coated circuit. Lung histopathological examinations of the lungs of the animals in group A showed no fibrin deposition, whereas most of the blood vessels of the lung preparations of the animals in group B were partially or completely occluded with fibrin. These results suggest that heparin-bonding greatly reduces the thrombogenicity of the extracorporeal circuit, and therefore it can reduce the need for systemic heparinization in an extracorporeal life support system.
Development of Total Artificial Heart with Economical and Durability Advantages
Authors: Yambe T. , Fukutome A. , Kobayashi S. , Nanka S. , Yoshizawa M. , Tabayashi K. , Takeda H. , Nitta S.
Published: March 2018

To develop a total artificial heart (TAH) pump system, we created a design paying particular attention to durability and cost. We adopted a pneumatically driven sac type artificial heart, where the configuration of the sac was decided according to the methodology of flow visualization. Its configuration is almost round to achieve as little stagnation as possible and a low turbulent flow. The main body of the sac was made using polyvinyl chloride (PVC) paste. The paste was poured into an external mold, and heated in a hot air drying oven. Coating was performed using polyurethane. The basic performance of this pump system was tested using a model circulation circuit, and a fitting study through acute animal experiment, using a healthy adult goat, was carried out. As for the TAH produced experimentally, a pump output exceeding 5.0 l/min in the model circulation circuit was provided. Implantation in the internal pleural cavity of a healthy adult goat, 55 kg in weight, proved possible and quite easy in comparison. It is thought that a more refined design in the connector part is desirable. Furthermore, a chronic experiment with the TAH will be carried out, and examination will need to be repeated in the future.
On-Line Hemodiafiltration with Pre- and Postdilution: Impact on the Acid-Base Status
Authors: Ahrenholz P. , Winkler R.E. , Ramlow W. , Tiess M. , Thews O.
Published: March 2018

With on-line formation of the substitution fluid, high substitution rates in predilution (PRD) and postdilution (POD) can be obtained (Fresenius 4008 On-Line HDF, Gambro AK 100 Ultra). The substitution fluid is branched off from the dialysate produced by the dialysate delivery system of the HDF machine. Under these conditions it is desirable to consider the effect of the different treatment modes on the acid-base status. Using Fresenius 4008 On-Line HDF machines, ESRD-patients were treated alternately with high-flux hemodialysis (HD), postdilution HDF (POD-HDF) and predilution HDF (PRD-HDF), while all other treatment parameters were kept constant, in particular the bicarbonate dialysate concentration. Plasma-HCO3, - pH and -pCO2 were measured and compared with the results of a multicompartment bicarbonate model developed by Thews. Also plasma-pO2 and K+ were measured. The results showed no significant differences between HD, POD- and PRD-HDF. Acidosis was corrected effectively and no excessive compensation of the acid-base disturbance was observed.
Assessment of Liver Function in Primary Cultures of Hepatocytes Using Diethoxy (5,6) Chloromethylfluorescein and Confocal Laser Scanning Microscopy
Authors: Anderson K. , Wilkinson R. , Grant M.H.
Published: March 2018

A method is presented which can be used to assess the function of hepatocytes in complex culture configurations without disrupting the integrity of the cell environment. It utilises a fluorescent probe for cytochrome P450 dependent mixed function oxidase (MFO) activity, diethoxy (5,6) chloromethylfluorescein, and confocal laser scanning microscopy. The MFO activity of individual cells in primary cultures of intact hepatocytes can be detected in situ, and quantified by image analysis. This may be a valuable means of monitoring the effect of culture conditions on the function of bioartificial liver devices, and could be used to assess the need for effective oxygenation of cells, the influence of shear stress and of exposure to patient serum during clinical use.
Evaluation of the Function of Primary Human Hepatocytes Co-Cultured with the Human Hepatic Stellate Cell (HSC) Line LI90
Authors: Okamoto M. , Ishida Y. , Keogh A. , Strain A.
Published: March 2018

Most bioartificial liver devices utilise primary hepatocytes alone although some have considered the use of non parenchymal cells in addition. However the effects of co-culture of human hepatocytes with different sinusoidal cell types has not been fully investigated. In this study we have examined the influence of co-culturing primary human hepatocytes with the human hepatic stellate cell (HSC) line, LI90. Cultures were monitored by light microscopy and on days 4, 8 and 14 urea synthesis and cytochrome P450 activity were measured. Morphologically LI90 cells proliferated to fill spaces between and into adjacent islands of hepatocytes. On day 14 cytochrome P450 activity in co-culture was significantly improved compared to hepatocytes cultured alone. By contrast, urea synthesis in hepatocytes was unaffected by single or co-culture. Therefore it can be concluded that a combination of primary human hepatocytes with LI90 cells is beneficial for growth and some stability of hepatocytes and may therefore be appropriate for seeding bioartificial liver devices.
Monitoring System for the Totally Implantable Ventricular Assist System by Use of Sensors for Virtual Reality
Authors: Yambe T. , Kobayashi S. , Nanka S. , Yoshizawa M. , Tabayashi K. , Takeda H. , Nitta S.
Published: March 2018

For the development of the totally implantable artificial organs, it is an important problem to monitor the conditions of the implantable devices, especially when used in clinical cases. In this study, we used position sensors for the 3-dimensional (3-D) virtual reality (VR) system monitor an implantable artificial heart. The sensors used in the experiments were 3-space Fastrak (Polhemus, USA). The position sensors using electro-magnetic forces were attached to the inner actuating zone. Sensitivity of the position sensors was in the order of around 0.8 mm. By use of these VR position sensors, we could easily detect the six degrees of freedom as x,y,z, and pitch, yaw, roll of these sensors. Experimental evaluation using a model circulation loop and healthy adult goats was performed. Experimental results suggest that our newly developed implantable sensors for monitoring the implantable artificial heart system were useful for sensing driving condition, thus possibly useful for the implantable devices for clinical usage.
Levels of Sustainable Aerobic Workload in Dialysis Patients
Authors: Capodaglio E.M. , Villa G. , Jurisic D. , Salvadeo A.
Published: March 2018

The aerobic performance of a heterogeneous group of 89 ambulatory medically stable patients on chronic hemodialysis was studied to define individual levels of the most acceptable metabolic workload. The patients performed a step test protocol (3 steps) with a cycle ergometer. Each step (25 Watt) lasted 6 min. Heart rate (HR), oxygen consumption (VO2), ventilation (VE), respiratory exchange ratio (RER), blood pressure (BP) and subjective ratings of dyspnea (CRd) and fatigue (CRf) levels were monitored throughout the test. The test was continued to exhaustion or to values of systolic arterial blood pressure (SABP) >240 mmHg, heart rate (HR) ≥ 85% max, or ST changes in ECG. In eleven patients (12.5% of the whole group) the test was interrupted within the first two minutes of exercise. In the remaining 78 patients, the maximum workload sustained for at least 3 min (MSW) was 25 Watts for 43 (48.5%), 50 Watts for 27 (30%), and 75 Watts for 8 (9%) patients. Performance was affected in a statistically significant manner by the subjects’ anagraphic age, but not by their dialytic age, hemoglobin (Hb) level or weight. Individual levels of tolerable workload were estimated for 60% of the group from the stability of physiological variables during 3 min, and from subjective ratings at a “moderate” level. This level corresponded to an average of 3.5±0.9 METs, at 60% of the HRmax, with a mean BP of 167±21/98±14 mmHg. This could become a safe starting point for a program of physical retraining.
Biocompatibility Evaluation of Polyamide Hemofiltration
Authors: Panichi V. , Bianchi A.M. , Andreini B. , Casarosa L. , Migliori M. , Depietro S. , Taccola D. , Giovannini L. , Palla R.
Published: March 2018

Introduction

Postdilution hemofiltration with a polyamide membrane is a renal replacement technique widely used, but very little information is available regarding the biocompatibility of this treatment. In this paper we report the results of an acute study of the biocompatibility of polyamide hemofiltration.

Patients and methods

Complement activation such as C3a and C5a Des Arg (RIA), granulocyte degranulation like alpha 1 elastase intradialytic increase (ELISA) and the expression of high affinity membrane receptors for IL-2 (anti-TAC) were determined. Beta 2-microglobulin (RIA) intradialytic decrease, as well as its convective removal, was evaluated. The nature of protein layer adsorbed onto the polyamide membrane, at the end of the dialytic session was investigated with a new immunohistochemical tecnique. Cell-associated cytokine concentration (like IL-1 beta and IL-1Ra - ELISA) was determined on mononuclear cell lysates.

Results

A low degree of complement activation was detected with the polyamide membrane when data were adjusted for hemoconcentration and for 1 m2 of membrane surface area. An important convective removal not only of Beta 2-microglobulin (258±20 mg/session), but also of the activated anaphylatoxins (225±76 ng/ml for C3a and 22.5±4 ng/ml for C5a) was revealed. A marked deposition of all coagulation factors with no detectable amount of immunoglobulins and complement factors was revealed on the polyamide membrane at the end of the dialytic session. No intradialytic (for IL-1beta) (from 14.1±3.0 to 13.5±2.9 pg/ 2.5 x 106 cell) and interdialytic (for IL-1Ra) (from 4572±1076 to 5408±615 pg/ 2.5 x 106 cell) cell-associated cytokine expression was induced by hemofiltration.

Discussion and Conclusion

Polyamide hemofiltration is a highly biocompatible technique due to the use of a synthetic membrane with a sterile reinfusion fluid and the convective removal of the activated anaphylatoxins and Beta 2-microglobulin.
Fever in Dialysis Patients with Recently Rejected Renal Allografts
Authors: Sever M.Ş. , TüRkmen A. , Yildiz A. , Ecder T. , Orhan Y.
Published: March 2018

Introduction

Fever of unknown origin is a complex problem in dialysis patients with recently rejected renal allografts, due to the contribution of the newly withheld immunosuppressive agents to the immunosuppression of uremia, resulting in an atypical presentation of infections, a main cause of fever in these cases.

Materials and Methods

Two dialysis patients with recently rejected renal allografts who were hospitalized because of fever of unknown origin are reported. Biochemical, bacteriological and imaging studies were performed for specific diagnosis.

Results

Extensive laboratory investigations failed to yield any diagnosis and allograft nephrectomy was performed in one patient, with a probable diagnosis of inflammation of the allograft, which resulted in no improvement. Eventually, both patients were found to have adrenal insufficiency responsible for the fever, which improved after steroid replacement.

Conclusions

Adrenal insufficiency should be suspected in all dialysis patients presenting with fever and atypical symptoms, but only after other potential causes are eliminated; since steroid administration may normalize fever regardless of the etiology, it may mask the signs and symptoms and delay the treatment of other (if any) underlying disorder(s).
Model-Based Dialysis Adequacy Prediction by Continuous Dialysate Urea Monitoring
Authors: Chiari L. , Cappello A. , Tartarini R. , Paolini F. , Calzavara P.
Published: March 2018

A modeling approach for on-line estimation of urea kinetics from continuous measurement of urea concentration in the effluent dialysate stream (DUN) is presented. On-line identification of urea kinetics response parameters is used to predict and update dialysis adequacy during the treatment. Dialysis adequacy can be quantified in several ways, but its strict dependence on final urea concentration is a major fact. For this reason, a good predictive skill on the time course of DUN may enable better performances in the control of dialysis outcome by treatment parameters adjustment. A post-filter enzymatic sensor performs continuous measurement of DUN on patients undergoing standard haemodialysis. To get an early prediction of the end dialysis urea level, the solution of a variable volume double-pool (VVDP) model is used, whose parameters are identified at each time on the basis of the past DUN history. Unlike the variable volume single-pool (VVSP) model, this enables a prompt and accurate estimation of the final DUN. In fact, after 75 min the estimates always differ by less than 10% from the values measured by the sensor at the end of the treatment. Moreover, values predicted by the model in the last hour always lie within 1% of measured final values. Realtime knowledge of an analytic expression for whole DUN time course also enables the accurate prediction of total removed urea, with no need of cumbersome dialysate collection techniques.
Conductivity: On-Line Monitoring of Dialysis Adequacy
Authors: Del Vecchio L. , Di Filippo S. , Andrulli S. , Manzoni C. , Corti M. , Barbisoni F. , Locatelli F.
Published: March 2018

Cardiovascular disease and the inadequacy of delivered dialysis are the main factors determining morbidity and mortality in dialysis patients. We have already demonstrated that a conductivity kinetic model makes it possible to match interdialytic sodium loading and intradialytic sodium removal (the main factor determining cardiovascular morbidity) without the need for blood samples and, thus, in routine clinical practice.

The aim of the present study was to test the possibility of using the conductivity method also to determine Kt/v without blood or dialysate sampling.

In 18 steady-state patients, the urea distribution volume (V) was kinetically determined once using ionic dialysance (D) values instead of those of effective urea clearance. One month later, the Kt/V was determined by using the current D and T values and the predetermined V (Dt/V), then compared with the equilibrated Kt/V computed by means of the SPVV kinetic model (eqKt/V). The mean value of Dt/V was 1.18 ± 0.15; while of eqKt/V it was 1.18 ± 0.16, with a mean difference of 0.00 ± 0.07.

The conductivity method therefore seems to be very promising not only for monitoring the sodium balance, but also for quantifying delivered dialysis. Since its simplicity and low-cost make it suitable for use at each dialysis session, the conductivity method could therefore lead to significant progress in dialytic practice by contributing to the elimination of the two main causes of morbidity and mortality in dialysis patients.
Chronic Hemodialysis: Kt/V or Solute Removal Index to Evaluate the Effective Delivered Dose?
Authors: Di Filippo S. , Manzoni C. , Corti M. , Locatelli F.
Published: March 2018

A standard for quantifying the hemodialysis dose has not yet been defined. Many authors suggest the use of an alternative method to Kt/V: the solute removal index (SRI).

We compared three methods based on blood-side urea determinations with the direct quantification method (DDQ) for estimating the delivered dialysis dose, expressed as SRI as well as Kt/V. Eight patients underwent three consecutive dialysis sessions, with the same dialytic efficiency. For each patient and each dialytic session the SRI and Kt/V were determined using the DDQ method and the single pool variable volume kinetic model, in its classical version (SPVV) as well by using the post-dialysis urea value determined 30 min after the end of the session (eqSPVV). Double pool Kt/V was also estimated by the Daugirdas-Schneditz rate equation.

Our results showed that the SPVV kinetic model significantly overestimated the delivered dialysis dose, the mean value of SRI and Kt/V were respectively 8.9% and 17% higher than those obtained by DDQ. The eqSPVV allowed the SRI to be estimated with a difference of -0.3% and Kt/V with a difference of -2% in comparison with DDQ. By using the Daugirdas-Schneditz rate of equation, which does not require blood samples to be drawn after the end of the session, the difference in Kt/V value was 3%.

Therefore, both the eqSPVV kinetic model and the Daugirdas method allow quantification of the delivered dialysis dose with results similar to those determined by DDQ, which cannot be routinely applied. Kt/V seems the best marker for dialytic doses quantification.
Effects of Blood Flow Pulse Frequency on Mass Transfer Efficiency of a Commercial Hollow Fibre Oxygenator
Authors: Fiore G.B. , Pennati G. , Inzoli F. , Mastrantonio F. , Galavotti D.
Published: March 2018

The clinical advantages achievable through pulsatile blood perfusion during cardio-pulmonary bypass have recently suggested the design of new pulsatile systems for extracorporeal circulation. Still it is not clear whether current commercial membrane oxygenators could be adopted with such systems, since their behaviour with pulsatile perfusion has not been satisfactorily documented yet. In a previous paper, we assessed that pulsatile perfusion of a widely used hollow fibre oxygenator (Sorin® Monolyth) at 60 bpm provides more time-consistent oxygen transfer than steady perfusion. The present work is aimed to evaluate how the pulse frequency influences the gas transfer performance of the same device. The oxygenator was subjected to in vitro trials using a roller pump with pulsatile module (Stöckert Instrumente®) to generate pulsed flow. Four different pulse frequencies (45, 60, 75 and 90 bpm) were investigated at a fixed blood flow rate (4.0 l/min). The experiments lasting six hours were carried out using bovine blood with inlet conditions according to AAMI standards requirements. Blood samples were withdrawn every hour and O2 and CO2 transfer rates were evaluated. The experimental findings confirm that with pulsatile blood flow no time decay take place during prolonged perfusion. Moreover, when pulse frequency increases, transition levels occur for both O2 and CO2. Over these thresholds gas transfer rates display significant increases (p < 0.05), though of little magnitude (up to 2.5% for oxygen over 60 bpm; up to 3.7% for carbon dioxide over 75 bpm).
Does the Extend of the Culture Time of Primary Hepatocytes in a Bioreactor Affect the Treatment Efficacy of a Bioartificial Liver?
Authors: Flendrig L.M. , Maas M.A.W. , Daalhuisen J. , Ladiges N.C.J.J. , La Soe J.W. , Te Velde A.A. , Chamuleau R. A.F.M.
Published: March 2018

The purpose of this study was to investigate whether the efficacy of our novel extracorporeal bioartificial liver (BAL) to support rats with complete liver ischemia (LIS) could be improved by extending the culture time of freshly isolated porcine hepatocytes from 14 hours to 38 hours. The results showed that survival as well as porcine hepatocyte integrity improved, the onset of coma delayed, and the ammonia levels decreased in LIS rats of the 38 hour group compared to the 14 hour group, but no statistically significant differences were observed. In the 38 hour group, but not the 14 hour group, the onset of hepatic encephalopathy was significantly delayed and ammonia metabolism significantly improved compared to the LIS rats in control groups that only received a glucose infusion or were connected to a BAL without cells. In conclusion, prolonged hepatocyte recovery favoured all investigated parameters, although not all observed effects were statistically significant. More research is required to find out how long primary hepatocytes should be cultured in a bioreactor for optimal BAL support.
Estimating Urea Clearance in Patients on Continuous Ambulatory Peritoneal Dialysis: A Multivariate Analysis
Authors: Murata G.H. , Tzamaloukas A.H. , Voudiklari S. , Dimitriadis A. , Balaskas E. V. , Nicolopoulou N. , Dombros N.
Published: March 2018

The purpose of this study was to determine if Kt/V urea in continuous ambulatory peritoneal dialysis (CAPD) could be estimated by a multivariate model based upon simple clinical observations. The study included 439 clearance studies in 301 CAPD patients followed in 8 dialysis centers. Weekly urea clearance, 24 h urine volume and 24 h drain volume were normalized to body water by the formulae of Watson (Kt/V, UV/V, and DV/V respectively). Adequate dialysis was defined as Kt/V ≥2.0 weekly. Subjects at 2 units were used to derive the models, while others were used for model validation. Stepwise multiple linear regression was performed on the derivation set (DS) to identify the clinical variables that correlated with Kt/V. The model was then used to estimate Kt/V for the validation set (VS). In the DS, 110 clearance studies were performed in subjects with residual renal function. Multiple linear regression showed that weekly Kt/V was defined by the expression: Kt/V = 1.48 + 24.1 (UV/V) + 2.92(DV/V) - 0.049 (serum creatinine) (r=0.750, p<0.001). In 204 VS studies, the correlation between estimated and measured Kt/V was 0.633. There were marked differences in the proportion of adequately dialyzed patients when Kt/V estimated from the formula shown was <2.0, between 2.0 and 2.3, and >2.3 weekly (7.9%, 54.7% and 79.7%, respectively; p<0.001). In the 33 studies done in DS anuric patients, regression analysis showed the following: Kt/V = 0.46 + 2.59 (DV/V) + 0.009(age) (r=0.562; p = 0.003). In 92 VS studies in anuric subjects, there was strong correlation between estimated and measured Kt/V (r=0.740). Again, there were marked differences in the frequency of adequate dialysis in anuric patients with estimated Kt/V <2.0, between 2.0 and 2.3, and >2.3 weekly (8.1%, 68.8%, and 100%, respectively; p<0.001). The risk of low Kt/V can be estimated by multivariate linear models requiring only simple clinical measurements.
In Vitro Thrombogenicity Testing of Artificial Organs
Authors: Paul R. , Marseille O. , Hintze E. , Huber L. , Schima H. , Reul H. , Rau G.
Published: March 2018

Thromboembolic complications remain as one of the main problems for blood contacting artificial organs such as heart valves, bloodpumps and others. In vitro evaluation of thrombogenesis in prototypes has not previously been part of the standard evaluation of these devices. In comparison to hemolysis testing, evaluation of the thrombogenic potential is more difficult to perform because of the complexity of the blood coagulation system. We present an in vitro testing procedure that allows the accelerated examination of the thrombogenic potential of different types of blood pumps. Additionally, first results are presented that indicate the reliability of the accelerated clotting test for mechanical heart valves. Results for the centrifugal pump BioMedicus and two microaxial pumps have shown typical thrombus formation at locations such as bearings.

The results indicate that the accelerated clotting test is an excellent addition to the much more expensive animal testing of artificial organs or assist devices. In vitro testing permits studies of thrombus formation to be performed at an early stage and at low costs and also facilitates a more precise investigation of device areas known to be potential hot spots for thrombus formation.
Dialysis Outcome Quality Initiative (DOQI) Guideline for Hemodialysis Adequacy
Authors: Di Giulio S. , Meschini L. , Triolo G.
Published: March 2018

The article about Dialysis Outcome Quality Initiative (DOQI), recently published by the National Kidney Foundation in The American Journal of Kidney Disease provides clear guidelines for adequacy of hemodialysis, peritoneal dialysis, vascular access and treatment of anemia in End-Stage Renal Disease (ESRD). If the dissemination of these guidelines actually increases Kt/V, an early improvement of the outcome of dialysis patients will be expected because there is a close correlation between dialysis dose and mortality. Mortality, unless high, is the main indicator of the efficacy of guidelines in ESRD. Other indicators are needed to assess the effects of the modification in clinical practice induced by DOQI at lower mortality, as in other western European countries. Quality of life adjusted for life expectancy defined Kt/V of 1.3 as the optimal cost-effective dialysis dose; large evidence is missing to support the use of higher doses or of high technology in hemodialysis treatment. Adequacy and uniformity of isolated hemodialysis procedures are accurately defined by DOQI. Quality assessment of integrated actions in overall commitment of ESRD patients (prevention and treatment of co-morbidity of uremia, renal transplantation programs, improvement of the communication with caregivers and family, enhanced fitness and ability to work) has still to be implemented with recommendations and indicators of the outcome. NKF-DOQI defined only dialysis adequacy; further work is necessary to assess the “optimal clinical practice” for ESRD patients.
Ganciclovir-Associated Hypercalcemia in a Renal Transplant Patient
Authors: Georgiev O. P. , Lal S.M. , Gupta N. , Ross G.
Published: March 2018

We describe a renal transplant patient who developed hypercalcemia during treatment with ganciclovir for cytomegaloviral (CMV) infection. To our knowledge such an association has not previously been reported. Hypercalcemia was associated with low levels of serum parathormone (PTH) and an increase in 1,25 dihydroxy vitamin D concentrations. The mechanism(s) of ganciclovir-associated hypercalcemia remains unclear.
Quality of Life and End Stage Renal Disease Therapeutic Programs
Authors: Mingardi G. ,   For the DIA-QOL Group, Mingardi G. , Marchesi D. , Perticucci E. , Rota S. , Tiraboschi G. , Cornalba L. , Brunzieri C. , Foroni I. , Lupi G. , Cortinovis E. , Ondei P. , Alongi G. , Lorenz M. , Apolone G. , Mosconi P. , Ruggiata R.
Published: March 2018

Because patients with ESRD cannot be cured of their underlying conditions and because the therapeutic programs have an important impact on the patients’ life style, the patient's own assessment of health should have a central place in clinical care. Until now, attention has almost exclusively focused on technical and clinical outcomes, and survival. Functional status, well-being and quality of life, satisfaction with care, or in other words “patient's experience”, have been only marginally considered. There is a growing recognition that use of mortality data alone is not the most effective way to asses the quality of care provided to these patients. Generic and disease-specific health issues can be investigated with the use of questionnaires, by asking questions that cover physical, psychological and social domains.

Health related quality of life data regarding chronic renal failure, dialysis and transplantation are briefly presented and discussed. These data show differences between patient's subjective feelings and physician's opinions about patients, between objective quality of life indexes and subjective quality of life scores. A more comprehensive view of our patients seems possible and useful.
Accreditation Manual for Nephrology
Authors: Oliva D.
Published: March 2018

The IRS did not develop a new theory of accreditation but drew up a methodology for assessing public policies, which internalised accreditation philosophy and was based on a theory of the decision-making process.

Two questions underlie this theory: 1) whether health is a professional organisation, a company or a public policy, 2) whether accreditation in the internationally accepted meaning of the term is the most effective system of continuous improvement for this sector as it is organised in Italy. According to the IRS, health is all three of these things and accreditation responds adequately to the complexity of the sector. In fact:

a) internalises professional knowledge (and is therefore ideal for a professional organisation);

b) it triggers a process of continuous improvement of the product/service supplied (and that is ideal for a company that must maintain the competitiveness of its product/service as high as possible);

c. it uses a methodology which highlights the mechanisms of interaction between the actors (a methodology udnerlying decision making theory where there are actors who decide, knowing that they have to find a consensus and who exchange resources in a virtuous circle.

The principal qualitative element identified by the IRS methodology was the internalisation by the health system of patients’ expectations and patients’ satisfaction in the welfare process.

The main feature of the accreditation methodology designed by the IRS is that the assessment focuses neither on structures (which would have been useful to measure the degree of reliability) nor on the compilation of behaviour guidelines, but is centred on the assessment of a function, on the quality of the provision of a specialist health service.

The decision to assess a specialist function (e.g. nephrology) and not a structure (e.g. a nephrology department or a hospital) gives maximum importance to the figure of the professional.
Management and Quality Control
Authors: Quintaliani G. , Cencetti S.
Published: March 2018

The economic approach of the industrial and commercial sector cannot be transferred to the medical one without proper measures. The final objective of the health service is not to gain profits but rather to achieve results in terms of health. Professional quality and, therefore, appropriateness becomes the foundation for proper management. In turn, appropriateness means to do the right things when they are useful regarding both the organisational, administrative, educational and training aspects and the medical ones. Management control is the right answer to this challenge to know and monitor consumption, strategies and results in relation to pre-established administration health policy objectives. Its purpose is to allow the organisation to carry out its objectives with the highest effectiveness and efficiency possible and it is joined with technical-professional elements which orient and support management in a logic of total quality. The adoption of the process of management control does not mean to turn doctors into managers. It must be hoped that doctors will understand the economic implications of the decisions made at clinical level as well as the technical-organisational ones. A medical action becomes effective if it is part of a system in which each person involved carries out his duties in an integrated logic where relationships are clearly defined. To decide what is appropriate, one refers to what is known and proven. It is clear that the problem of quality must be faced firmly and systematically. The activation of a quality program is not only based on the definition of “good practice”, in terms of procedures, protocols, pathways and reference parameters for measuring quality but rather on the introduction of clinical methods that can guarantee a series of highly important opportunities.
Accreditation and Certification
Authors: Setti Bassanini M.C.
Published: March 2018

In Italy the debate has focused on three different assessment systems: accreditamento autorizzativo (regulatory accreditation), accreditamento di eccellenza (excellence accreditation), and certification.

Regulatory accreditation verifies the conformance to a set of quality standards that entitle an organisation to the status of belonging to the NHS.

Excellence accreditation attempts to maintain incremental improvement of the quality of services. Certification is a means by which an indipendent third party declares that a determined product or process conforms to the ISO 9000 set of standards; the main objective of certification is to increase the “credibility” of a company on the market in order to orient and at the same time assure customers. Certification loses meaning in a regulated market, as the Italian NHS, in which there is a distinction between the consumer and the paying body.

Regulatory accreditation should be deeply rooted in regional planning; the recognition of accredited organisations should be the result of a demonstrated capacity to co-operate in achieving the goals of regional planning and not of conformance to organisational standards.

Regional experiences of regulating accreditation show a high level of contamination between systems for quality assessment. The large number of standards proposed seemed to be redundand with respect to the aims that should be pursued by a regulating accreditation system.

The furthering of quality in the NHS requires a complex system of quality assessment within which a plurality of subjects, each with different interests, work together to determine the final result by each one setting up procedures consistent with its own particular problems: the institutions set up regulatory accreditation and the professions develop excellence accreditation in their individual professional associations. What is important is to establish relationships across the various levels so as to give the whole system cohesion and consistency.
Hydrodynamical Comparison of Aortic Arch Cannulae
Authors: Verdonck P.R. , Siller U. , De Wachter D.S. , De Somer F. , Van Nooten G.
Published: March 2018

The high velocity of blood flow exiting aortic arch cannulae may erode atherosclerotic material from the aortic intima causing non-cardiac complications such as stroke, multiple organ failure and death. Five 24 Fr cannulae from the Sarns product line (straight open tip, angled open tip with and without round side holes, straight and angled closed tip with four rectangular, lateral side holes), and a flexible cannula used at the University Hospital of Gent (straight open tip) are compared in an in vitro steady flow setup, to study the spatial velocity distribution inside the jet. The setup consists of an ultrasound Doppler velocimeter, mounted opposite to the cannula tip in an outflow reservoir. An elevated supply tank supplies steady flow of 1.3 L/min of water. Exit forces at various distances from the tip are calculated by integrating the assessed velocity profiles. The pressure drop across the cannula tip is measured using fluid filled pressure transducers. The four sidehole design provides the lowest exit velocity (0.85 versus 1.08 m/s) and force per jet (0.03 vs 0.15–0.20 N). The round sideholes are useless as less than 1% of the flow is directed through them. Furthermore, the use of angled tip cannulae is suggested because the force exerted on the aortic wall decreases the more the angle of incidence of the jet deviates from 90°. Pressure drop is the lowest for the 4 side hole design and highest for the open tip and increases when an angled tip is used.
Medical Knowledge, Quality of Life and Accreditation of Quality in Health Care the Perspective of the Clinical Nephrologist
Authors: Zoccali C.
Published: March 2018

The problem of Quality has three dimensions: the dimension of quality of life (the patients, perspective), the dimension of quality of medical knowledge and of the appropriate use of medical technology (i.e. the “evidence based” medical approach to clinical decision making) and the dimension of accreditation of health care providers.

The problem of keeping clinicians well updated is a difficult one but there are solutions. The medical literature can be selectively but thoroughly analysed and on the basis of high quality studies specific recommendations (i.e. guidelines) can be produced. Scientific societies are now making major efforts to produce high quality guidelines for the treatment of patients with chronic renal failure and for those on chronic dialysis. The DOQI and the Standards Document by the Renal Association offer first class examples of how scientific knowledge can be translated into clear practice guidelines.

As far as the dimension of quality of medical knowledge is concerned, there is now increasing evidence that the taking into full account of quality of life issues such as those regarding the physical, psychic and social dimensions of health improves substantially patient's satisfaction and the patient-doctor relationship. Quality of life considerations are now fully considered when evaluating the efficacy erythropoietin in the treatment of uraemic anemia.

If we accept the perspective that health care organisations should aim at excellence, the performance of a given provider can be evaluated on the basis of various indicators and its performance made transparent to the potential users. The internet has become the most accessible source of such kind of information and it can be easily forecasted that the performances of all major hospitals and health care organisations will soon be in the public domain.
Liver Assist Systems: State of the Art
Authors: Arkadopoulos N. , Detry O. , Rozga J. , Demetriou A. A
Published: March 2018

Attempts to develop liver support systems for the treatment of patients with liver failure have ranged from use of plasma exchange to utilization of charcoal columns and extracorporeal devices loaded with liver tissue. However, no system has achieved wide clinical use and - in the absence of liver transplantation - severe hepatic failure continues to be associated with significant morbidity and mortality. In this paper, the authors review the current status of liver assist systems and summarize their clinical experience with a xenogeneic cell based-bioartificial liver.
Factors Affecting the Respiratory Ratio during Cardiopulmonary By-Pass
Authors: Boschetti F. , Pennati G. , Montevecchi F.M.
Published: March 2018

Despite the wide use of hypothermic cardiopulmonary bypass (CPB) during open heart surgery there is little information about the patient metabolism. In particular no complete studies addressed the assessment of the respiratory ratio (RR) during CPB at different core temperatures. Therefore a clinical study was performed in order to evaluate the oxygen consumption (VO2) and carbon dioxide production (VCO2) in adult patients with valvular or coronary heart disease undergoing CPB. Twenty-five patients (16 male, 9 female) aged between 26 and 76 (54.2±12.4 mean±SD) were the subjects of this study. Measurements (102) were taken at various perfusion flow rates (from 1.6 to 2.9 L/min−1 · m−2) and temperatures (from 24 to 37°C). Arterial and mixed venous gas analyses were performed and O2 and CO2 concentrations were calculated, including the carbamate contribute. We calculated VO2, VCO2 and then RR from artero-venous differences in O2 and CO2 contents. Both VO2 and VCO2 showed a positive linear correlation with temperature (r=0.82 and r=0.59 respectively) and with blood flow rate (r=0.61 and r=0.29 respectively). The mean RR was 0.78±0.28 and more than 84% of RR values fell in the range 0.5–1.2. No significant correlation between RR and temperature and blood flow rate was observed. VCO2 and RR showed a positive linear correlation with the gas to blood flow rate ratio (r=0.37 and r=0.49 respectively). (Int J Artif Organs 1998; 21: 802–8
Blood Separation with Two Different Autotransfusion Devices: Effects on Blood Cell Quality and Coagulation Variables
Authors: Rosolski T. , Matthey T. , Frick U. , Hachenberg T.
Published: March 2018

The quality of blood products obtained from two different autotransfusion devices (CATS-Fresenius and Sequestra 1000 - Medtronic) was tested in 27 patients undergoing elective orthopaedic surgery. Blood products provided from our institutional blood bank (n = 16) served as controls. Hemodiluted blood was separated into platelet poor plasma (PPP), platelet rich plasma (PRP), and packed red cells (PRC) and analysed for blood cell count, fibrinogen concentration, thromboplastin time, partial thromboplastin time, platelet aggregation and platelet recovery rate. Coagulation variables showed no differences between the CATS-group (n = 14) and the Sequestra 1000-group (n = 13). The volume of PRP was lower in the Sequestra 1000-group (45 ± 3 ml vs. 89 ± 1 ml, p < 0.05), but hematocrit was higher (14.4 ± 7.8% vs. 8.5 ± 2.8%, p < 0.05). PPP produced with CATS contained a higher concentration of white blood cells (0.6 ± 0.2 Gpt/l vs. 0.1 ± 0.01 Gpt/l, p < 0.05) and thrombocytes (163 ± 74 Gpt/l vs. 11 ± 12 Gpt/l, p < 0.05). Hematocrit of PRC was significantly higher in the CATS-group (73.8 ± 2.0% vs. 69.0 ± 6.5%, p < 0.05). Blood products were of high quality in both groups and comparable to or superior than blood products provided from our institutional blood bank
Haemodynamic Changes in Patients Undergoing High-Risk PTCA under Protection of Transfemoral Heart-Lung Machine Support with Centrifugal Pumps
Authors: Waldenberger F.R. , Borges A. , Schubel J. , Baumann G. , Konertz W.
Published: March 2018

Patients with a high risk for myocardial revascularization by cardiological or surgical means can be supported during high-risk PTCA with mechanical circulatory support (supp HR-PTCA). Between November 1994 and June 1997 we performed 28 supp HR-PTCA's under protection of a heart-lung machine (HLM) with femoro - femoral cannulation under regional anesthesia.

We approached 2.8±1.5 stenoses and 1.7±0.6 vessels per patient. Primary success rate was 95 percent of the treated vessels. During unloading, pulmonary artery mean pressure fell to 42±29% of the starting value. and LVEDP was decreased to 36±42%. Mechanical unloading also resulted in a significant reduction of left ventricular volumes (unloaded LVEDVI and LVESVI represent 76.8% and 76.6% of pre-unloaded values, respectively, p<0,05). All patients except one survived the procedure and could be discharged from the hospital.

Femoro-femoral cardio-pulmonary bypass under regional anesthesia provides sufficient protection for high risk PTCA procedures and enables high risk patients to benefit from coronary revascularization.
Effects of Dialysis Membrane Nature on Intradialytic Phagocytizing Activity
Authors: Colì L. , Tumietto F. , De Pascalis A. , La Manna G. , Zanchelli F. , Isola E. , Perna C. , Raimondi C. , De Sanctis L.B. , Marseglia C.D. , Costigliola P. , Stefoni S.
Published: March 2018

Blood-membrane contact in the extracorporeal circuit affects the activation of many biological systems. Among these, phagocytizing activity has been reported to be influenced by the nature of the hemodialysis membrane used, whether cellulosic or synthetic.

This work reports on an ex-vivo, comparative test between cellulosics and synthetics concerning the effects of blood-membrane contact on the polymorphonucleate and monocyte phagocytizing function, both during and after the hemodialysis session.

By means of flow cytometry, we evaluated the capacity for phagosoma formation and oxidative burst both in polymorphonucleates and monocytes. Ten hemodialysis patients were included in the study. Six separate dialysis procedures for each patient were considered, one per dialyzer (3 cellulosic and 3 synthetic membranes). Tests were performed at 15', 60', 210’ and 4 hours after the session end. Comparative evaluation was made according to Student's t test.

Polymorphonucleate phagocytosis and oxidative burst activation were globally more marked for synthetic than cellulosic membranes, tending to level out in the post-dialysis. This result could be affected by their functional exhaustion following pulmonary sequestration. Monocyte intradialytic phagocytosis and oxidative burst proved more activated by cellulosic membrane. All differences tended to vanish in the post-dialysis.