Web Correspondent Report on Nephrology in Italy

by Giuseppe Quintaliani

Dr Giuseppe Quintaliani Nephrology and Dialysis Unit Ospedale Silvestrini Perugia, Italy

 

The 2003 Congress of the Italian Society of Nephrology will be hosted in Bologna (May 28-31)

Introduction

Nephrology is a branch of medicine that has increased considerably in Italy both in terms of quality and quantity. Dialysis, which was carried out in such a sporadic way in the 1960s, has improved dramatically thanks, not only to the technical resources that have been made available by industry, but also to the Italian social system that has made suer that all patients who need dialysis have access to it. Indeed, the principles of solidarity and of non-exclusion from therapy, have surely been the key to sucess giving full treatment to the uremic population.
Many of the methods that have been developed to improve the technical and methodological aspects of the various types of dialysis, are a source of pride for Italian researchers. The list of improvements they have brought about would be very long; it is enough to remember their contributions regarding improved connections in peritoneal dialysis or the models that make extracorporeal dialysis more physiological. Companies have made more and more equipment available with computerized biofeedback systems and technological innovations of materials used throughout the entire process of dialysis. New materials, especially those regarding filters for dialysis, have been widely used in Italy, and many patients have greatly benefited from them.

History

Italian nephrology has always been an international point of reference. On 28 April 1957, the Italian nephrologic scientific community founded the Italian Society of Nephrology (SIN) (www.sin-italia.org) having M. Bufano as its first president.
The first congress was held in 1957, and since then the annual event has taken place regularly with increasing participation. The next congress will be held in Bologna where, for three days, such issues will be dealt with as the new challenges concerning genetics, the progress that has been made in immunological diseases, dialysis and the growing importance of the relationship between the heart and kidney (http://www.sin-italia.org/congress/congdb/default.asp?year=2003). At present there are about 2000 members who take part in numerous study groups, established under the aegis of the Society, that deal with such varied aspects of nephropathy (http://www.sin-italia.org/gruppi/gruppi.htm) as hypertension, glomerulonephritis, diabetes, pregnancy, computers, etc.
SIN has a national register of dialysis and transplant patients (http://www.sin-ridt.org/sin-ridt/sin-ridt.org.htm) which has collected data for over four years. It is an aggregated model that begins with the individual regional situations then grouped into a single group of aggregated data. The patients’ names are recorded in the individual regional registers, their data are processed for corrections and validity, and then the final data are sent to the national register. The information contained in the national register is discussed at the society’s annual assembly and then published on the internet. Every Italian region is represented, and the data of about 90% of the patients in dialysis are present. SIN has also developed an exhaustive collection of guidelines and diagnostic protocols.

Dialysis

In Italy, there are about 37,000 patients in dialysis and about 9,500 transplanted patients. There are 400 centres throughout the country. The centres may also be connected with limited assistance centres (LAC) where a physician goes at regular intervals. Different organisational models have developed in the various regions. LACs are widespread in northern Italy and treat about 40% of the patients; in the South, the percentage of patients treated without a physician’s assistance is negligible since 50-60% are treated in private clinics. In the major cities, the organisation of dialysis centres is very complex, since they include a wide range of activities such as nephrologic in-patients, Day Hospital services, consulting rooms and, in some cases, transplants. On the other hand, simple dialysis centres merely offer dialysis and a consulting room; in-patients are kept in the internal medicine department. Many regions have regularised the minimum standards that a nephrologic and/or dialysis centre must necessarily follow to obtain accreditation (Institutional accreditation, accreditation between equals and clinical government [GIN 19, S 21-2002]).

The incidence and prevalence of patients in dialysis are continually increasing, and the data in the register regularly bear witness to this trend. 83% of the patients begin with extracorporeal dialysis, 74% using bicarbonate. About 10-15 % use one of the mixed techniques with a certain stability over time. Unfortunately, the rate of home dialysis remains low, with a decreasing trend: about 16% for both extracorporeal and peritoneal. Also in this case there is a sharp difference between northern and southern Italy where home dialysis is almost nonexistent.
The causes of admission to dialysis are more and more due to chronic degenerative diseases (diabetes, vascular diseases, hypertension). Mortality has been stable for years, between 10 and 11.

This figure is a source of pride for Italian nephrology: this, and the fact that no patient is denied treatment, whatever his clinical condition.

 

Nurses

Nurses obtain a diploma after a three-year university course. With this diploma they may gain access to nephrology departments without further training. Within the various nephrology units they undergo appropriate training according to the section in which they will work (CAPD, HD, in-patients, transplants). There are no precise data regarding the number of nurses presently working in the Italian nephrology departments. Also, the number of patients assigned to each nurse during dialysis varies greatly from region to region. In several northern regions the number is fixed at three patients per nurse while in others the number ranges from 4 to5 patients per nurse. The figure of dialysis technician also exists in Italy but they are few in number and there are contrasting opinions regarding their legal status. Italian nurses belong to the European EDTNA which holds an annual meeting in Italy. The last meeting was heald in Viterbo in April. "Quality and its problems" was its main theme (www.edtna-erca.it).