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The Oxford Classification of IgA Nephropathy (IgAN) identified mesangial hypercellularity (M), endocapillary proliferation (E), segmental glomerulosclerosis (S), and tubular atrophy/interstitial fibrosis (T) as independent predictors of outcome. Whether it applies to individuals excluded from the original study and how therapy influences the predictive value of pathology remain uncertain. The VALIGA study examined 1147 patients from 13 European countries that encompassed the whole spectrum of IgAN. Over a median follow-up of 4.7 years, 86% received renin-angiotensin system blockade and 42% glucocorticoid/immunosuppressive drugs. M, S, and T lesions independently predicted the loss of estimated glomerular filtration rate (eGFR) and a lower renal survival. Their value was also assessed in patients not represented in the Oxford cohort. In individuals with eGFR less than 30 ml/min per 1.73 m(2), the M and T lesions independently predicted a poor survival. In those with proteinuria under 0.5 g/day, both M and E lesions were associated with a rise in proteinuria to 1 or 2 g/day or more. The addition of M, S, and T lesions to clinical variables significantly enhanced the ability to predict progression only in those who did not receive immunosuppression (net reclassification index 11.5%). The VALIGA study provides a validation of the Oxford classification in a large European cohort of IgAN patients across the whole spectrum of the disease. The independent predictive value of pathology MEST score is reduced by glucocorticoid/immunosuppressive therapy.

Side effects of steroid use have led to efforts to minimize their use in transplantation. Two corticosteroid-free regimens were compared with a triple immunosuppressive therapy. Data from the original intent-to-treat (ITT) population (153 tacrolimus/basiliximab [Tac/Bas], 151 tacrolimus/MMF [Tac/MMF], and 147 tacrolimus/MMF/steroids [control]) were analyzed in a 12-month follow-up. Percentage of graft survival were 92.8%, 95.4%, and 95.9% (KM estimates 89.9%, 95.3%, 95.9%), percentage of surviving patients were 98.7%, 98.0%, and 100% (KM estimates 95.9%, 92.8%, and 100%). During months 7-12, graft loss occurred in 3 Tac/Bas, 2 Tac/MMF, and zero control patients, patient deaths in 1 Tac/Bas, 2 Tac/MMF, and zero control, and biopsy-proven acute rejection episodes in 4 Tac/Bas, 3 Tac/MMF, and zero control. Mean serum creatinine at month 12 was 141.9 +/- 69.6 microM, 144.0 +/- 82.1 microM, and 134.5 +/- 71.2 microM (ns). New-onset insulin use in previously non-diabetic patients at month 12 was 1/138, 6/127, and 4/126. Patient and graft survival as well as renal function at 12 months were not different between patient groups, despite considerably higher rates of acute rejection occurring within the first six months after transplantation in both steroid-free patient groups. Tac/Bas therapy might offer benefits in terms of a trend for a more favorable cardiovascular risk profile.

Cardiac screening is recommended to prevent cardiovascular death after renal transplantation. This retrospective observational study illustrates the results of application of a cardiac assessment algorithm in a series of 558 renal transplant candidates at a single center in Turin, Italy. A dipyridamole-stress sestamibi myocardial scintiscan (DMS) performed in 302/558 (54.1%) cases was positive in 52 (17.2%), negative in 200 (66.2%), borderline in 16 (5.3%), and with signs of previous necrosis in 34 (11.4%). Coronary lesions detected by angiography in 48.1% of the 52 positives were treated medically (13.5%) or by percutaneous/surgical procedure (34.6%). Coronary lesions were detected in 14.1% of asymptomatic population subgroup. The minor and major cardiovascular event rates and the cardiovascular death rate were 1.9%, 0%, and 0%, respectively, in positive DMS group (high-cardiological risk) vs. 10%, 4.5%, and 3.5% in the negatives (p > 0.5; n.s.). It is suggested that not increased cardiovascular event or deaths rates in the high-risk group reflect early coronary lesion detection and correction. Since 55.9% of cardiovascular events or deaths occurred in the negative group more than 24 months after the DMS, its mandatory repetition every two yr after a negative finding is recommended.

The rate of the clinical adoption of the so-called pre-emptive transplantation is widely different among countries. In North America it represents 25 % of the total living donor transplantations; in Norway and Sweden it is 15 % and 9 %, respectively, of all grafts performed; in Italy it is less than 1%, whilst in countries like Austria, Germany and Ireland pre-emptive transplantation is nonexistent. Some concern on this type of transplantation was raised in the Seventies and were mainly based on the evidence that uraemia has an immunosuppressive effect, which could be weaker in the pre-dialysis period. Several clinical observations in the pre- cyclosporin era supported this assumption. Starting from the Eighties, however, several studies have demonstrated that pre-emptive transplantation may yield better recipient and graft survival. Moreover, a recent retrospective study, based on higher than 8000 living donor grafts that included both treated and untreated by long-term dialysis before transplantation, showed in the pre-emptive cohort a 52 % reduction in graft losses after the first year and also a lower incidence of acute rejections. Among the advantages of pre-emptive transplantation we find better rehabilitation and especially a lower risk of job loss. The risk of poorer patient compliance, as initially pointed out, has no longer been reported and can be overcome by adequate psychological preparation of the patient. Most centres performing pre-emptive transplantation favour the use of living donor because of the general shortage of cadaver kidney vs. the increasing number of dialysed patients on the waiting list. Nevertheless, in special circumstances (national programs with short waiting lists, uremic type I diabetics, children, primary type I hyperoxaluria), some AA also recommend the use of the cadaver donor.

Background: Therapeutic compliance is fundamental on dialysis; however following a therapy requires a prior understanding of it. Aim of the study was to assess the need and interest for information on dialysis efficiency and to prepare a dedicated teaching tool., Methods: 72 patients, on hemodialysis in two limited-care satellite units, were given a questionnaire testing knowledge and interest on dialysis efficiency. In a subsequent second phase, following patients' suggestions, a cartoon book was prepared and opinions recorded., Results: 63 patients' returned the questionnaire. 79.4% had basic knowledge on routine blood tests, 30.1% were aware of their specific meaning. All patients asked for further information, preferring books to other media. The book "Kt/V as cartoon" was distributed; 71.2% read it, 93% scored it as good-very good. In the Unit employing flexible dialysis schedules, 22/42 patients increased dialysis time., Conclusions: Despite insufficient knowledge on dialysis efficiency, patient interest is high. An educational program is feasible and may also give practical results, such as self-increase in dialysis time.

Therapeutic compliance and patient education are presently considered crucial parts of end-stage renal disease (ESRD) therapy. In the center where Italian home and self-care dialysis treatment started, an education program was designed as multi-step pathway--following patients from chronic renal failure to dialysis and eventual graft--employing lessons, booklets, and books. Each step was validated in various subsets of patients. Lessons involved two hours of informal discussion on the main aspects of ESRD and renal replacement therapy (RRT); booklets were created from tape recordings of the lessons. Patient participation was good, with 28 of 33 patients on charge in the center for 6 months or more taking part in more than one lesson in 1999. In 16 of 16 patients who answered a questionnaire after two lessons, expressed opinion was "good" to "fair." All asked for further material. With regard to books, 500 copies of the book What does dialysis mean? were given out in the region; this book was validated in 22 patients on peritoneal dialysis (PD) and 18 on hemodialysis (HD). It helped patients to accept dialysis in 65% of cases and to comprehend it in 90%. Four thousand copies of the book Stories, containing 18 interviews on transplantation, were printed, and this book was validated in 21 patients on self-care and 35 on hospital dialysis (potential candidates for graft). Of 56 patients, 53 asked for further material; 19 changed their initial opinion (10 choose transplantation, despite initial skepticism; 9 put off transplantation, despite initial acceptance). On a local scale, the program led 12 of 18 new patients, who followed at least part of the program, to choose self-dialysis (PD, home, and self-care dialysis).

Mannosidosis is an inherited autosomal recessive mucopolysaccharidosis. Patients affected accumulate mannose-rich compounds in various tissues and excrete an increased quantity of oligosaccharides with mannose as a component. A case of type II mannosidosis with end-stage renal failure is reported. The patient, after 6 years of regular hemodialysis treatment, received a kidney transplant. At the time this article was written, the graft was functioning well and thesaurismotic renal deposits had not been observed. The clinical course of mannosidosis was silent and the patient's quality of life was good. Although the risk of recurrence could not be excluded, it seems that renal transplantation can be safely offered to patients affected with mannosidosis type II, in the rare setting of chronic renal failure.

Over a 10-year period, 1,990 end-stage renal disease patients in 30 centers were treated with continuous ambulatory peritoneal dialysis by the Italian Cooperative Peritoneal Dialysis Study Group. At the start of treatment, patients had an average age of 58.4 years, with a 66% prevalence of one or more clinical risk factors for premature death. Patient survival was 51% and 33% at 4 and 8 years on continuous ambulatory peritoneal dialysis, respectively, and technique survival was 62% and 48%, respectively. Occurrences of peritonitis progressively reduced until they reached an incidence of 0.50 episodes/yr in the last 5 years (1985 to 1989). Hernias and catheter-related problems did not influence the dropout rates. These Italian Cooperative Peritoneal Dialysis Study Group results demonstrate that continuous ambulatory peritoneal dialysis is a viable dialysis technique for long-term treatment of chronic renal failure and that it is an effective alternative to hemodialysis, especially for older and high-risk patients.

CAPD outcomes were compared between a group of 301 diabetic patients (mean age +/- SD, 58.9 +/- 12.7 years, 55.8% males) and a group of 1689 non-diabetic patients (mean age +/- SD 57.8 +/- 14.8 years, 55.9% males) treated in 30 centres participating in the Italian Cooperative Peritoneal Dialysis Study Group from 1980 to 1989, with follow-up observation periods of 444 years (mean +/- SD, 1.48 +/- 1.24) and of 3502 years (mean +/- SD, 2.07 +/- 1.91) respectively. CAPD was the first modality for 87.2% of diabetics and 78.1% of non-diabetics (P < 0.001). The percentage of patients who needed a partner for CAPD was 45.9% in diabetics and 30.2% in non-diabetics (P < 0.001). In diabetics compared with non-diabetics, cardiovascular diseases and cachexia were nearly twice and infections other than peritonitis more than three times as frequent in causing death. In diabetics, survival was significantly worse (P < 0.0001) and the relative risk of death 2.13 times higher (P < 0.001). The technique survival and the relative risk of drop-out were not significantly different in the two groups. Clinical problems were the most important cause of drop-out among diabetics. The probability and relative risk of drop-out due to peritonitis, as well as of the first peritonitis episode, were not significantly different between the two groups and between diabetics using or not using intraperitoneal insulin. Days per patient year of hospitalization, excluding the first, were 18.4 in diabetics and 14.3 in non-diabetics. CAPD-related problems caused hospitalization in a similar way in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Numerical and functional markers of peripheral lymphocytes were adopted to study the influence of cimetidine on the immune response in immunocom-promized patients. Twenty-three patients on regular dialysis treatment, who had been given cimetidine (400 mg daily) for peptic ulcer, were studied during a follow-up of 3 months. Thirty healthy people served as controls for the study of the immunological parameters, i.e. DNCB and PPD skin tests, E-rosetting assays, monoclonal antibodies to T-cells, membrane immunoglobulins for the B-cells, serum immunoglobulins and complement. Before therapy was started CMI was impaired in all patients, with a significant reduction in the E-rosette count (P less than 0.01) and depressed DTH (DNCB, PPD). The number of active E-rosettes and OKT4 subsets increased slightly during the period of treatment, though this finding was not confirmed by functional in vivo tests. No change was observed in the B-lymphocyte count and in serum immunoglobulins or complement. The fact that treatment with cimetidine does not seem to influence the immune response in patients on RDT, may suggest that this therapy does not restore the principal immunopathological disorder of these patients, and further justifies its use in patients awaiting renal transplantation or in those who have been given transplant.

This study reports the endoscopic and histological aspects of gastrointestinal mucosa in a consecutive series of 249 patients with chronic renal failure on conservative hemodialysis, who were awaiting renal transplantation. At endoscopy the mucosa was normal in 54.2% of the cases and revealed gross inflammatory changes in 34.1%. Duodenal ulcers were found in 11.2% of patients with only one gastric ulcer. Of the 28 duodenal ulcers, 16 were active and 12 inactive lesions. Gastric biopsies sampled from 44 non-ulcer patients showed signs of chronic gastritis in 29.6%, atrophic gastritis in 18.2, and reported normal in 52.3% of the cases. The above findings were not affected by the ages of patients or by the total duration of hemodialysis treatment. It is concluded that patients with chronic renal failure share the same risk of developing chronic peptic ulcers as the general population. Moreover, the overall endoscopic and histological appearance of the mucosa in these patients appears not to differ from data reported in the general population.

Urokinase treatment, previously employed with success in the declotting of deep venous thrombosis and arteriovenous shunts in patients undergoing regular dialytic treatment (RDT), was used in 23 cases of arteriovenous fistula thrombotic occlusion in 18 RDT patients. The treatment was successful in 65.2% of the cases without any negative side effects, except 1 case which may have developed a pulmonary embolism. Patients with severe hypofibrinolysis may need larger doses or may have a recurrence of the thrombotic episode. All therapeutic failures correlated with the presence of fibrosis or sclerosis.

Begun in 1979, the Italian CAPD Study Group monitored prospectively six years of CAPD experience (1980-1985) in 24 centers with 1107 end-stage renal disease (ESRD) patients (age 56.4 +/- 13.7 years). Compiled yearly, the clinical and therapeutical data were processed on a PDP 11-32 computer, according to UCLA BMPD-1L procedure. The survival rate was conditioned by age (more than 70) and by major clinical risk factors, with a large fraction of the deaths due to cardiovascular causes (40.6%) and cachexia (17.8%). The progressive reduction of peritonitis incidence (1/18.5 episodes/patient-month globally reached at the end of 1985) was due mainly to the wide spread adoption of the "Y" connection set (76% for 1985) and contributed to a decrease in drop-outs to 7.5% of 676 patients on CAPD during 1985.