The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.

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The fundamental concept for the selection of high-performance membrane is based on solute removal capability and biocompatibility. From this principle, the selection guidelines for high-performance membrane are recommended as follows: (1) The currently available products do not provide coverage of the necessary \'balance between solute removal and biocompatibility\' in a single dialyzer for all the dialysis patients. Therefore, it is advisable to choose a high-performance membrane taking into consideration the balance between the solute removal capacity necessary for the patient and the severity of complications that is considered a surrogate marker for biocompatibility. (2) There is an increasing demand in dialysis therapy for new biocompatibility indices such as \'reducing blood pressure variability during dialysis\', \'decreasing oxidative stress\' and \'delaying the onset or progression of complications\'. High-performance membranes developed to address these needs include the ethylene-co-vinyl alcohol copolymer (EVAL) (R) membrane, cellulose triacetate, polymethylmethacrylate, vitamin E-coated polysulfone (PS) membrane, and PS membrane hemodiafiltration filter.

BACKGROUND: A clinical audit is used to verify the application of evidence-based clinical guidelines. Our regional section of the Italian Society of Nephrology was the first to establish a region-based program of clinical audits of compliance with guidelines for treating osteodystrophy and anemia of patients on chronic dialysis. This study summarizes the main results of the 2 audits of the Piemonte region.
METHODS: Structured questionnaires were sent twice to all of the 22 dialysis centers of Piemonte and to the Center of Valle D\'Aosta for an Audit on Osteodystrophy (in 2000 and 2004) and for the Audit on Anemia (2003). The questionnaires were meant to evaluate the clinical schedule of treatment relative to calcium-phosphate balance and anemia in dialysis patients.
RESULTS: All centers responded, showing low levels of agreement with the targets of Italian guidelines. In sum, in 2000 only 27% of centers had more than 70% of patients with serum phosphate <5.5 mg/dL, but that rate had increased to 33% in 2004. Only 35% (in 2000) and 40% (in 2004) of the centers had more than 90% of patients with Kt/V >1.2. The Audit on Anemia showed a median of 42% of patients with hemoglobin between 11 and 12 g/dL, and only 2 centers had more than 70% of patients above this target.
CONCLUSIONS: The first result of our pioneering experience was that we found that compliance with minimal levels of care was still inadequate, with regard to hyperphosphatemia, dialysis adequacy and anemia. Nevertheless, the 2nd Audit on Osteodystrophy showed a relative improvement in the results. But, most importantly, this open regional report has encouraged comparisons, and motivated centers to adopt a strategy of understanding, addressing and correcting inadequate levels of care, and furthermore increased satisfaction with the care being offered.

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Adequate dialysis is defined as the quantity and the quality of the dialysis that is necessary for the patient to remain in good state, with no uremic symptoms, obtaining a longer survival with the best possible corrections of his uremia-related metabolic and systemic changes, and with the minimum possible morbidity in addition to a good quality of life. The good operation of a peritoneal dialysis schedule calls for a set of criteria and standards, as well as management clinical protocols according to which the healthcare team manages the dialysis technique and its complications, and uniforms the steps to be taken. Such protocols should be agreed to by the whole of team that enforces them, and should be submitted to a continuous update process based on the team\'s own experiences and also on the scientific literature. The results are periodically evaluated. Useful quality standards of clinical management, based on scientific evidence and on the opinions of expert nephrologists are needed with the aim to go in depth into specific aspects of the daily clinical action, by means of a rigorous and regular systematic review process that reflects all new advancements and technologies. The U.S. National Kidney Foundation (NKF) published in 1997 the Dialysis Outcome Quality Initiative (DOQI) which were the first action guidelines, with the aim to improve dialysis\' quality and results. The objective of the clinical guidelines is to act as an updating method and to unify criteria by contributing scientific evidence.

A biochemical definition and classification system for acute renal dysfunction is long overdue. Its absence has impeded progress in clinical and even basic research concerning a syndrome associated with mortality rates of 30 to 80%. No definition of acute renal dysfunction will be perfect, but the absence of a definition or, worse, more than 35 separate definitions, as found in the literature, is unacceptable. Many of the challenges, considerations, and controversies associated with achieving consensus and developing a classification for acute renal dysfunction are addressed. Recommendations for validating a classification system are also considered.

OBJECTIVE: To assess the impact of health professionals\' involvement in the implementation of practice guidelines aimed at reducing the use of pre-operative tests in patients at low anaesthetic risk undergoing elective surgery.
METHODS: A 6 month (September 1997 to February 1998) strategy based upon organization of local meetings involving health professionals from six hospitals of Canton Ticino (Switzerland).
METHODS: Observational study (pre/post) of pre-operative test utilization between March 1996 and December 1998.
METHODS: A total of 17,978 patients admitted for elective surgery over the study period. The latter was modelled in six intervals, three before (baseline), one during, and two after (adoption) guidelines implementation, respectively. For each time interval the proportion of patients undergoing pre-operative tests was estimated. Multilevel logistic regression analysis was used to assess patient likelihood [expressed as the odds ratio (OR)] of undergoing a diagnostic test in each period, using the implementation interval as the reference category.
METHODS: Change in patient probability of undergoing pre-operative tests in the adoption interval.
RESULTS: Adoption of the recommendations was associated with 81% [OR = 0.19; 95% confidence interval (CI) 0.15-0.23] reduction of patient probability of undergoing coagulation test, 73% (OR = 0.27; 95% CI 0.23-0.33) for glycaemia, 62% (OR = 0.38; 95% CI 0.33-0.44) for azotaemia, 57% (OR = 0.43; 95% CI 0.36-0.51) for chest X-ray, 49% (OR = 0.51; 95% CI 0.44-0.60) for creatinemia, and 43% (OR = 0.57; 95% CI 0.48-0.69) for ECG. Overall, these findings corresponded to a cost saving of 67,890 Swiss francs (US$42,000) for the last quarter under study.
CONCLUSIONS: This study indicates that an implementation strategy based upon direct involvement of end users in the identification of possible barriers to change can be successful in promoting the use of practice guidelines.

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In this review we have summarized the guidelines on hemodialysis prescription and dose in order to attempt of simplify an issue often difficult to understand for the majority of physicians. In brief, we start from the results of National Cooperative Dialysis Study and then we describe the Urea Kinetic Model, the KT/V and the Protein Catabolic Rate (PCR). Simplified formulas to obtain KT/V and PCR are also reported. At the end, the modalities related to postdialytic blood samples and connected problems are described.