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Pregnancy after kidney transplantation is highly successful, though not without risk. A new national Dutch study of a large series of pregnancies in transplanted women highlights the complexities of pregnancy in this cohort and notes a move toward pregnancies in women with "less-than-perfect" graft function. We discuss these new data defining pregnancy outcomes and the ethical and clinical challenges that may arise in these mothers., (Copyright © 2022. Published by Elsevier Inc.)

Background: Although several studies suggest the benefit of a low-protein diet supplemented with amino acids and keto acids (sLPD) in delaying the initiation of hemodialysis, evidence on whether these nutritional approaches could delay the timing of preemptive transplantation is lacking., Methods: Retrospective nationwide cohort study, from Taiwan's National Health Insurance Research Database. Patients having undergone a first preemptive kidney transplantation between 2001 and 2017 were identified and divided into two groups according to the presence of sLPD treatment or not. The primary outcome was the time between the diagnosis of advanced CKD and transplantation. Secondary outcomes were post-transplantation adverse events., Results: A total of 245 patients who received their first preemptive kidney transplantation were identified from the nationwide database; 63 of them had been on an sLPD prior to transplantation (sLPD group). The duration between the day of advanced CKD diagnosis and the day of transplantation was significantly longer in the sLPD group compared with the non-sLPD group (median duration: 345 vs. 220 days, p = 0.001). The risk of post-transplantation adverse events did not differ between the two groups., Conclusions: Within the limits of its observational, retrospective design, this is the first study to suggest that nutritional management with sLPDs can safely delay the timing of preemptive kidney transplantation.

Introduction: Living donor kidney transplant (LDKT) is one of the best therapeutic options for end-stage kidney disease (ESKD). Guidelines identify different estimated glomerular filtration rate (eGFR) thresholds to determine the eligibility of donors. The aim of our study was to evaluate whether pretransplant donor eGFR was associated with kidney function in the recipient., Methods: We retrospectively studied LDKT recipients who received a kidney graft between September 1, 2005, and June 30, 2016 in the same transplant center in France and that had eGFR data available at 3, 12, 24, and 36 months posttransplant., Results: We studied 90 donor-recipient pairs. The average age at time of transplant was 51.47 ± 10.95 for donors and 43.04 ± 13.52 years for recipients. Donors' average eGFR was 91.99 ± 15.37 mL/min/1.73 m2. Donor's age and eGFR were significantly correlated (p < 0.0001, r2 0.023). Donor's age and eGFR significantly correlated with recipient's eGFR at 3, 12, and 24 months posttransplant (age: p < 0.001 at all intervals; eGFR p = 0.001, 0.003, and 0.016, respectively); at 36 months, only donor's age significantly correlated with recipient's eGFR. BMI, gender match, and year of kidney transplant did not correlate with graft function. In the multivariable analyses, donor's eGFR and donor's age were found to be associated with graft function; correlation with eGFR was lost at 36 months; and donor's age retained a strong correlation with graft function at all intervals (p < 0.001)., Conclusions: Donor's eGFR and age are strong predictors of recipient's kidney function at 3 years. We suggest that donor's eGFR should be clinically balanced with other determinants of kidney function and in particular with age., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically women's kidney health on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state in which acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. Various autoimmune and other conditions are more likely to impact women, with profound consequences for child bearing and the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we know and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

In advanced chronic kidney disease, obesity may bring a survival advantage, but many transplant centres demand weight loss before wait-listing for kidney graft. The case here described regards a 71-year-old man, with obesity-related glomerulopathy; referral data were: weight 110 kg, Body Mass Index (BMI) 37 kg/m², serum creatinine (sCr) 5 mg/dL, estimated glomerular filtration rate (eGFR) 23 mL/min, blood urea nitrogen (BUN) 75 mg/dL, proteinuria 2.3 g/day. A moderately restricted, low-protein diet allowed reduction in BUN (45-55 mg/dL) and good metabolic and kidney function stability, with a weight increase of 6 kg. Therefore, he asked to be enrolled in a weight-loss program to be wait-listed (the two nearest transplant centres required a BMI below 30 or 35 kg/m²). Since previous low-calorie diets were not successful and he was against a surgical approach, we chose a qualitative, ad libitum coach-assisted diet, freely available in our unit. In the first phase, the diet is dissociated; he lost 16 kg in 2 months, without need for dialysis. In the second maintenance phase, in which foods are progressively combined, he lost 4 kg in 5 months, allowing wait-listing. Dialysis started one year later, and was followed by weight gain of about 5 kg. He resumed the maintenance diet, and his current body weight, 35 months after the start of the diet, is 94 kg, with a BMI of 31.7 kg/m², without clinical or biochemical signs of malnutrition. This case suggests that our patients can benefit from the same options available to non-CKD (chronic kidney disease) individuals, provided that strict multidisciplinary surveillance is assured., Competing Interests: Luigi Teta works for as consultant for the Bioimis Accademia Alimentatre; Irene Capizzi received and unrestricted grant from the Bioimis Accademia Alimentare, through the University of Torino, under the responsibility of Giorgina B Piccoli. None of the other Authors had any conflict of interst.

Background: Kidney transplantation (KT) may restore fertility in chronic kidney disease (CKD). The reasons why maternofetal outcomes are still inferior to the overall population are only partially known. Comparison with the CKD population may offer some useful insights for management and counselling.Aim of this study was to analyse the outcomes of pregnancy after KT, compared with a large population of nontransplanted CKD patients and with low-risk control pregnancies, observed in Italy the new millennium., Methods: We selected 121 live-born singletons after KT (Italian study group of kidney in pregnancy, national coverage about 75%), 610 live-born singletons in CKD, and 1418 low-risk controls recruited in 2 large Italian Units in the same period (2000-2014). The following outcomes were considered: maternal and fetal death; malformations; preterm delivery; small for gestational age (SGA) baby; need for the neonatal intensive care unit; doubling of serum creatinine or increase in CKD stage. Data were analyzed according to kidney diseases, renal function (staging according to CKD-epidemiology collaboration), hypertension, maternal age, parity, ethnicity., Results: Maternofetal outcomes are less favourable in CKD and KT as compared with the low-risk population. CKD stage and hypertension are important determinants of results. Kidney transplantation patients with estimated glomerular filtration rate greater than 90 have worse outcomes compared with CKD stage 1 patients; the differences level off when only CKD patients affected by glomerulonephritis or systemic diseases ("progressive CKD") are compared with KT. In the multivariate analysis, risk for preterm and early-preterm delivery was linked to CKD stage (2-5 vs 1: relative risk 3.42 and 3.78) and hypertension (RR 3.68 and 3.16) while no difference was associated with being a KT or a CKD patient., Conclusions: The maternofetal outcomes in patients with kidney transplantation are comparable with those of nontransplanted CKD patients with similar levels of kidney function impairment and progressive and/or immunologic kidney disease.

Background: Kidney transplantation is the treatment of choice to restore fertility to women on renal replacement therapy. Over time, immunosuppressive, support therapies and approaches towards high-risk pregnancies have changed. The aim of this study was to analyse maternal-foetal outcomes in two cohorts of transplanted women who delivered a live-born baby in Italy in 1978-2013, dichotomized into delivery before and after January 2000., Methods: A survey involving all the Italian transplant centres was carried out, gathering data on all pregnancies recorded since the start of activity at each centre; the estimated nationwide coverage was 75%. Data on cause of ESRD, dialysis, living/cadaveric transplantation, drug therapy, comorbidity, and the main maternal-foetal outcomes were recorded and reviewed. Data were compared with a low-risk cohort of pregnancies from two large Italian centres (2000-14; Torino and Cagliari Observational Study cohort)., Results: The database consists of 222 pregnancies with live-born babies after transplantation (83 before 2000 and 139 in 2000-13; 68 and 121 with baseline and birth data, respectively), and 1418 low-risk controls. The age of the patients significantly increased over time (1978-99: age 30.7 ± 3.7 versus 34.1 ± 3.7 in 2000-13; P < 0.001). Azathioprine, steroids and cyclosporine A were the main drugs employed in the first time period, while tacrolimus emerged in the second. The prevalence of early preterm babies increased from 13.4% in the first to 27.1% in the second period (P = 0.049), while late-preterm babies non-significantly decreased (38.8 versus 33.1%), thus leaving the prevalence of all preterm babies almost unchanged (52.2 and 60.2%; P = 0.372). Babies below the 5th percentile decreased over time (22.2 versus 9.6%; P = 0.036). In spite of high prematurity rates, no neonatal deaths occurred after 2000. The results in kidney transplant patients are significantly different from controls both considering all cases [preterm delivery: 57.3 versus 6.3%; early preterm: 22.2 versus 0.9%; small for gestational age (SGA): 14 versus 4.5%; P < 0.001] and considering only transplant patients with normal kidney function [preterm delivery: 35 versus 6.3%; early preterm: 10 versus 0.9%; SGA: 23.7 versus 4.5% (P < 0.001); risks increase across CKD stages]. Kidney function remained stable in most of the patients up to 6 months after delivery. Multiple regression analysis performed on the transplant cohort highlights a higher risk of preterm delivery in later CKD stages, an increase in preterm delivery and a decrease in SGA across periods., Conclusions: Pregnancy after transplantation has a higher risk of adverse outcomes compared with the general population. Over time, the incidence of SGA babies decreased while the incidence of 'early preterm' babies increased. Although acknowledging the differences in therapy (cyclosporine versus tacrolimus) and in maternal age (significantly increased), the decrease in SGA and the increase in prematurity may be explained by an obstetric policy favouring earlier delivery against the risk of foetal growth restriction., (© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background: A successful pregnancy is an exceptional event on dialysis. Few data are available comparing pregnancy rates on dialysis, transplantation and the overall population. The aim of the study was to assess the incidence of live births from mothers on chronic dialysis compared with the overall population and with kidney transplant patients., Methods: The setting of the study is in Italy between 2000-12. Data on dialysis was aquired by phone inquiries that were carried out between June and September, 2013, involving all the public dialysis centres in Italy; the result was a 100% response rate. The date included was end-stage renal disease, type of dialysis, residual glomerular filtration rate, changes in dialysis and therapy, hospitalization; week of birth, birth weight, centile; and outcome of mother and child. Information on transplantation was acquired by inquiry by the kidney and pregnancy study group who were contacted by phone or e-mail; the result was a 60% response rate. Data concerning prevalence of women in childbearing age (20-45) were obtained from the Italian Dialysis and Transplant Registries (2010-11 update). Official site of the Italian Ministry of Health., Results: During the study period, 23 women on dialysis (three on peritoneal dialysis) delivered live-born babies and one woman delivered twins (24 babies). Three babies died in the first weeks-months of life (including one twin); 19 of 21 singletons with available data were pre-term (33.3% <34 weeks); the prevalence of children <10th gestational age-adjusted centile was 33.3%. Birth weight and gestational age were lower in children from on-dialysis mothers as compared with 110 pregnancies following kidney graft, (weight: 1200 versus 2500 g; gestational age: 30 versus 36 weeks; P < 0.001). Incidence of live-born babies was inferred as 0.7-1.1 per 1000 female dialysis patients aged 20-45 and 5.5-8.3 per 1000 grafted patients in the same age range (Italian live-birth rates: 72.5 per 1000 women aged 20-45 years)., Conclusions: Having a baby while on dialysis is rare but not impossible, though early mortality remains high. There is a 'scale of probability' estimating that women on dialysis have a 10-fold lower probability of delivering a live-born baby than those who have undergone renal transplantation, who in turn have a 10-fold lower probability of delivering a live-born baby as compared with the overall population., (© The Author 2014. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Focus groups are increasingly employed in clinical practice as their flexible structure permits the range and depth of experiences of health service users and chronically ill individuals to be explored and recorded. A focus group workshop on quality of life was held in March 2007 involving a group of patients either awaiting transplantation, following transplantation, or with a family member who had already undergone renal replacement therapy (RRT). After intensive discussion the group produced the following consensus points. Before talking about quality of life, physicians should call us by our names, instead of by the names of our diseases. The true disease is the ignorance of diversity. The life of a person with a chronic disease is entangled with the disease and with the fear of the disease. It is impossible to consider one's disease separately from one's life, loves, failures, families, and dreams. To evaluate the quality of our life means knowing us, as people. We do not need other numbers. Physicians often see us as boxes, with a disease inside. That's not what we are. We need time. Discussions about the quality of life should include the people around us. The disease steals a lot from you, but it also gives you something in return. We do not feel sick. The main result was to highlight the close relationship between quality of life and quality of care. Underlining the importance of a global approach to health, and the role of the physician as a leader in all aspects of care.

Acute pyelonephritis is a common complication of kidney transplantation, occurring in up to 1% of grafts. Diagnosis is mainly clinical and atypical presentations have seldom been reported. The diagnostic role of imaging techniques has not been defined. Five cases of acute graft pyelonephritis are reported (three kidney, two pancreas-kidney grafts). The patients (median age 48 years) comprised three females and two males. Median post-transplant follow-up was 3 months, with three patients having predisposing factors for diabetes and one for an enteric bladder. None of the patients presented the 'classic' diagnostic tetrad (i.e. fever, positive urine cultures, low urinary tract symptoms and serum creatinine increase); although, at diagnosis, two of five patients presented with fever, one had increased creatinine levels and one had positive urine cultures. Of note, three patients had leucocyte casts at urinary sediment analysis, thus raising clinical suspicion. Renal ultrasounds were negative in all patients. Renal (99m)Tc-MAG3 (mercaptoacetyltriglycine) scintigraphy, which was used for the definition of kidney function impairment (one patient) or because of the presence of urinary casts (three patients), or after the biopsy diagnosis to locate the parenchymal lesions (one patient), was positive in all patients. The presence and pyelonephritic origin of the parenchymal lesions was confirmed by nuclear magnetic resonance or computed tomography scans. Acute graft pyelonephritis may develop in the absence of a full-blown clinical picture. Smouldering symptoms may occur in the presence of large perfusion deficits. (99m)Tc-MAG3 scintigraphy could be an important diagnostic tool in such cases.

Context: Organ shortage for transplantation is a crucial problem; educational interventions may increase donations and decrease opposition., Objective: To test the efficacy of an educational programme on opinions on organ transplantation and kidney donation., Design and Participants: Cluster Randomized Controlled Trial: eight intervention and eight control schools were randomly selected from the 33 public schools that agreed to participate. Targets: students in the last 2 years of secondary school (17-18 years); seven schools per group completed the study. EDUCATIONAL PROGRAMME:, Intervention: first questionnaire (anonymous); 2 h lesson in each class; 2 h general session with patients and experts; second questionnaire., Control: questionnaires., Main Outcome Measures: Differences between questionnaires (comparative analysis); interest; satisfaction with the programme; (cross-sectional analysis)., Results: 1776 first, 1467 second questionnaires were retrieved. Living kidney donation: at baseline 78.8% of students would donate a kidney to a relative/friend in need. The answers were unaffected by type of school but depended on sex (females more prone to donate, P<0.001); the answers did not change after the lessons. Cadaveric kidney donation: baseline opinions were mixed (intervention schools: 31.5% yes, 33.7% no, 34.8% uncertain), depending on type of school (classical-scientific high schools more positive than technical institutes, P<0.001), sex (males more prone to donate, P<0.001). Answers on living and cadaveric donation were correlated (P<0.001). The educational intervention increased favourable (31.5 to 42.9%) and uncertain (34.8 to 41.1%) opinions and decreased negative ones (33.7 to 16%) (P<0.001)., Conclusions: Educational interventions are effective in increasing interest and improving opinions about cadaveric organ donation.

Background: There is an increasing tendency to allocate kidneys from marginal donors in older recipients. This combination optimizes the uses of an expanded donor pool but demands attention for the higher nephrotoxic sensitivity of the kidney and the increased immunosuppression vulnerability of the elderly recipients. We aimed to reduce these hazards by means of a calcineurin-free induction therapy followed by a maintenance regimen targeted to minimize/withdraw steroid., Methods: Eighty-eight single (43%) or double (57%) transplant recipients (58.4+/-5.7 years) from 88 marginal donors (67+/-8.3 years) received monoclonal anti-IL-2 receptor antibodies, mycophenolate mofetil (MMF), and steroid. When serum creatinine was less than 2.6 mg/dL, tacrolimus was started and MMF was withdrawn when the tacrolimus trough level was above 15 ng/ml. Steroid was tapered to 5 mg at day 45 and then progressively reduced., Results: Overall patient and graft survival at the first and fourth year were respectively 100 and 96%, and 98 and 79%. Acute rejection rate was 13.6% (12/88), creatinine clearance remained stable (48.2 ml/min at the sixth month, 50.9 ml/min at 48th month). At the first, second, third, and fourth years, 23, 69, 80, and 100% of recipients were off steroids. For those on steroids, mean dose was respectively 2.6 mg/day from month 12. No recipient re-assumed steroids, Conclusions: In the "old-for-old" allocation, the calcineurin-inhibitor avoidance at induction and the steroid withdrawal/minimization during the tacrolimus-based maintenance regimen allow a low acute rejection rate, a stable renal function, and favorable recipient and graft outcomes.

Vascular lesions are an increasing challenge after renal transplantation due to the wider indications for recipients and acceptance criteria for donors. Diagnostic approach and prognostic interpretation are still matter of controversy. The case reported herein may summarize some of the issues in this regard. A 54-year-old woman, on renal replacement therapy since 1974, and a kidney graft recipient from 1975 to 1999, received a second graft in 2001. The donor age was 65 years (cold ischemia 22 hours; two mismatches). The early posttransplant follow-up was characterized by delayed graft function, hypertension, and diabetes. During the initial hypertension workup, renal graft ultrasound (US) Doppler demonstrated increased vascular resistances, stable over time (resistance index 0.74 to 0.77); renal scintiscan displayed homogeneously parenchymoa and angio-magnetic resonance imaging (MRI), an homogeneous parenchymal vascularization. Initial immunosuppression with tacrolimus and steroids was modulated by adding mycophenolate mofetil to taper tacrolimus (to reduce nephrotoxicity and hypertension). Despite this, kidney function slowly deteriorated; serum creatinine reached 3 to 3.5 mg/dL by the second year. After a severe hypertensive crisis with unchanged scintiscan and US doppler examinations, angio-MRI revealed the almost complete disappearance of parenchymal enhancement beyond the lobar arteries. A renal biopsy confirmed the severe vascular damage. The patient was switched to rapamycine and a low-dose of an angiotension converting enzyme (ACE) inhibitor. She did relatively well (serum creatinine 2.2 to 3 mg/dL) for 6 months, when rapid functional impairment forced her to restart hemodialysis. This case, almost paradigmatic of the problems occurring when the rigid vasculature of long-term dialysis patients is matched with "marginal kidneys," suggests that MRI may be a sensible good to define vascular damage in the grafted kidney.

Despite the relatively little space for transplantation in most medical schools, this issue is considered interesting by the students both for its clinical and ethical implications. The students were asked to choose a particular aspect of nephrology for a 2-hour case discussion. They chose the case of a 35-year-old female, kidney transplant recipient now 1.5 years postoperatively, who was coming to seek advice about pregnancy. The aim of the present work is to report an integration between narrative and evidence-based medicine (EBM) approaches. The search strategy was developed within a multidisciplinary working group, two of whose members were also masters in the methodology of systematic revisions. The first step in the discussion was the identification of ethical and methodological problem. In a rapidly developing field, books are unlikely to be able to give updated information. One needs to interact with electronic databases. In this context, no randomized controlled trial on pregnancy is expected. The evidence is likely to be heterogeneous. Prenatal care delivery differs around the world in part related to attitudes toward pregnancy, which depend upon religion and traditions. The second step was the definition of the search strategy. The third step, was selecting and cataloging the evidence. The titles and abstracts retrieved by the search strategy (272 items) were examined to identify full papers to be retrieved. The evidence retrieved was screened for the type of paper (reviews, primary studies, case reports, case series) and for the authors to give an indirect idea of duplicate publication bias. Teaching a complex and ever-changing subject, such as kidney transplantation, is a difficult task. The case of a young woman seeking information on the probability to undergo a successful pregnancy was particularly likely to exemplify the importance of being aware of the biases of the book-based information and on the need to interact with the internet. The search strategy developed by the working group of postgraduate trainees allowed students to have a direct experience with the complexity of the field. This preliminary study, as the basis for development of a checklist informed consent form on pregnancy in kidney transplantation, may give a first rough quantification of the work needed by a physician who wants to have a direct idea of the odds and risks of pregnancy in kidney transplant patients.

Renal transplantation in patients who have undergone coronary revascularization remains a matter of concern, few experiences have been reported in literature. From January 1997 to March 2003, 23 previously revascularized patients underwent renal transplants from cadaveric donors. We analyzed patient survival and cardiac events in this group of patients (group A) versus a similar population of 38 revascularized patients who were still on dialysis (group B) on the active waiting list (awl). After a similar follow-up (29.30 +/- 21.34 months versus 32.98 +/- 31.33 months; P = .56), survival was 100% for renal transplant patients and 94.74% for dialysis patients, two of whom (5.26%) died from acute myocardial infarction and four (10.52%) were excluded from the waiting list because of cardiac problems. The event-person ratio was 0.51 for group A patients (75% of events clustered within the first 6 months) and 0.71 for group B. The need for therapy with nitrates decreased from 11/23 (47.8%) to 6/23 (26%) after transplant. The ejection fraction remained stable (53.82% +/- 10.4% vs pre-Tx value of 54.8% +/- 9.4%). Renal survival was 100% (sCr = 1.4 +/- 0.4 mg/dL). Although no statistical significance has emerged, there was a general trend in favor of transplanted patients. On the basis of this experience we believe that coronary revascularization per se should no longer be a matter of concern for renal transplantation, which could be superior to dialysis for this type of patient.

Unlabelled: Living kidney donation is an important clinical option, encountering different fortunes in the world., Aim: To analyse the opinions of a large subset of older teenagers attending high school (7999 students, median age 18) on different aspects of living kidney transplantation., Methods: Analysis of semistructured questionnaires submitted within an educational campaign on dialysis and transplantation in the high schools of Torino and its county (about 2,000,000 inhabitants)., Results: Over 90% of the students had already heard of transplantation, mainly via television (88.4% county, 84.5% city). 80% would donate a kidney to a family member (3.5% wouldn't, 16.5% uncertain); answers were correlated with sex (females more than males p<0.0001), school type (istituti tecnici versus licei p=0.007), interest (yes versus other p<0.0001). A lower percent of individuals would receive a kidney (58.4% county, 59.4% city), only 10% would ask for donation. Over 40% of students consider legally buying a kidney a patient's right, only 26.6% would discourage this choice. The answers were correlated with the reverse pattern as for non-mercenary donation with type of school (licei more than istituti tecnici: p<0.0001), sex (males versus females p<0.0001), interest (not versus yes: p=0.002)., Conclusions: Teenagers are favourable towards all forms of living kidney donation. The lower prevalence of positive answers on acceptance versus donation suggests that fears of endangering the donor's health may be one of the causes for a low living donation rate in our setting. The mixed answers on mercenary donation suggest discussing this complex issue in future educational programs.

Background: Restarting dialysis after kidney transplantation is a critical step with psychological and clinical implications. Maintenance of residual renal function a known factor affecting survival in chronic kidney disease, has so far not been investigated after a kidney transplantation., The Case: A 54-year-old woman who started dialysis in 1974 (first graft, 1975-1999) received a second "marginal" kidney graft in February 2001 (donor age, 65 years). Her chronic therapy was tacrolimus and steroids. She had a clinical history as follows: nadir creatinine level of 1.5 mg/dL, moderate-severe hypertension, progressive graft dysfunction, nonresponsiveness to addition of mycophenolate, tapering FK levels, and a rescue switch from tacrolimus to rapamycin. From October to December 2003, the creatinine level increased from 2-2.8 to 7 mg/dL. Biopsy specimen showed malignant and "benign" nephrosclerosis, posttransplantation glomerulopathy, and tacrolimus toxicity. Chronic dialysis was started (GFR <3 mL/min). Rapamycin was discontinued. Dialysis was tailored to reach an equivalent renal clearance of >15 mL/min (2 sessions/wk). Blood pressure control improved, nephrotoxic drugs were avoided, and fluid loss was minimized (maximum 500 mL/hr). By this policy, renal function progressively increased to GFR >10 mL/min in May 2004, allowing a once or twice weekly dialysis schedule, with good clinical balance, and obvious advantages for the quality of life., Conclusion: This long-term patient, who restarted dialysis with severely reduced renal function, regained sufficient renal function to allow once weekly dialysis. Thus, careful tailoring of dialysis sessions at the restart of dialysis may allow preservation of residual kidney function, at least in individuals for whom a subsequent graft is unlikely.

The aim of this study was to report on the production and the opinions of a video movie on transplantation and organ donation. The video was developed by a medical school student with the help of the students and teachers of a high school for applied arts. For this task, the making of the video was included in the high school program of the participating class. The students were tutored by their photography teacher. The video movie lasts about 50 minutes. Each "scene" lasts no more than 5 minutes, to avoid reducing the attention level. The choice of a nonmedical frame helped to have some moments to digest the technical information and to stress the importance of the patient-physician relationship. The video was employed as a part of small-group lessons in the nephrology course. A semistructured anonymous questionnaire gathered the opinion of 65 students at the end of the lessons. Student satisfaction was high; the median score was the highest (8, range 6 to 10) for the lesson based upon the movie, as compared with the conventional ones on chronic kidney disease or dialysis (7, range 5 to 10). As far as the authors know, this is the first experiment of a multimedia approach, dedicated to medical and nonmedical targets, developed as a graduation thesis in an Italian Medical School. In conclusion, the positive opinions of the students, who highly appreciated the peer-developed message, may suggest implementing such nonconventional educational approaches to support human resources and enthusiasm for kidney transplantation among the new generations.

Background: Continuing Education in Medicine (CEM) underlines the importance of updates and information for the health care team. Our aim was to describe the organization and results of a CEM course "educate to organ donation" that involved the nursing team in an educational experience with high school students. The course consists of theory (4 hours; the physician-patient relationship, the educational role of the nurse, the teaching policy, checklist, and results of a school education program) and practice (10 hours; the attendants join the teaching team in the classrooms and in the plenary session). Analysis of anonymous questionnaires performed after the course contained semistructured questions and analog scales., Results: The first acknowledgment came from the Cabinet of Public Health, which gave the maximum number of credits (14 for 14 education hours)., Participation: presently 40 nurses, about 40% of those working in the renal unit (over 30 CEM courses are available in the hospital). Satisfaction: Overall score was median 8.5 (6 to 10) including teaching materials = 8 (4 to 10). Among the theoretical part, the lesson on patient-physician relationship obtained the highest score. The main drawback was the shortness of the practical part. The classroom meeting achieved a median score of 9.5 (7 to 10), the general session = 9 (5 to 10). All but one nurse registered for an "advanced" course, giving more time to the practical part (20 hours)., Conclusion: CEM may represent an important way to deliver education on transplant-related issues to patients and to the general population.

In the aging of Western populations, decreased mortality is counterbalanced by an increase in morbidity, particularly involving chronic diseases such as most renal diseases. The price of the successful care of chronic conditions, such as cardiovascular diseases or diabetes, is a continuous increase in new dialysis patients. However, the increased survival of patients on chronic renal replacement therapies poses new challenges to nephrologists and calls for new models of care. Since its split from internal medicine, nephrology has seen a progressive trend toward super specialization and the differentiation into at least 3 major branches (nephrology, dialysis, and transplantation), following a path common to several other fields of internal medicine. The success in the care of chronic patients is owed not only to a careful technical prescription, but also to the ability to teach self-care and attain compliance; this requires good medical practice and a sound patient-physician relationship. In this context, the usual models of care may fail to provide adequate coordination and, despite valuable single elements, could end up as an orchestra without a conductor. We propose an integrated model of care oriented to the type of patient (tested in our area especially for diabetic patients): the patient is followed-up by the same team from the first signs of renal disease to eventual dialysis or transplantation. This model offers an interesting alternative both for patients, who usually seek continuity of care, and for nephrologists who prefer a holistic and integrated patient-physician approach.

This report describes the rapid and complete reversal of proteinuria after preemptive transplantation in diabetic nephropathy. Case 1 was a 42-year-old woman with type 1 diabetes (before pancreas-kidney graft: serum creatinine 1.6 mg/dL and proteinuria 9.1 g/day; 1 month after pancreas-kidney graft: proteinuria 0.3 g/day and creatinine 1.3 mg/dL). Case 2 was a 48-year-old man with type 2 diabetes (before kidney graft: creatinine 2 mg/dL and proteinuria 5.9 g/day; 1 month after: proteinuria 0.7 g/day and creatinine 1.1 mg/dL). The proteinuria pattern changed (pre: glomerular nonselective, tubular complete; post: physiologic). Renal scintiscan (99mTC-MAG3) demonstrated functional exclusion of the native kidneys, despite high pretransplant clearance (> 50 mL/min). The effect was not linked to euglycemia or readily explainable by pharmacologic effects (no difference in renal parameters after pancreas transplantation with the same protocols). These data confirm the efficacy of preemptive kidney and kidney-pancreas transplantation in diabetic nephrotic syndrome and indicate that a regulatory hemodynamic effect should be investigated.

Background: Interest in the humanities in the medical school is growing; while several medical schools, mainly of Anglo-Saxon background, have developed dedicated courses, the experience in Italy is limited., Methods: Since the academic year 2000 to 2001, a discussion of ethical problems was implemented in the nephrology course (fourth year of the Medical School of Torino, Italy; overall 6 years). In 2002 to 2003, a case entitled "Retransplantation of Multiple Organs (Prog Transplant 2002)" was discussed in 2 hours of small-group tutorial teaching: a boy received a renal graft at age 5, failed at age 7 due to recurrent glomerulonephritis, required a heart-kidney graft at age 11, and a second heart-kidney graft at 17. Student opinions were gathered by anonymous semistructured questionnaires at the beginning of the lessons as a basis for discussion., Results: Following the lessons all students returned the questionnaires (n = 104). In the absence of competition for allocation, retransplantation was approved by 76.2%, unacceptable for 1% (22.9% uncertain-blank). With a waiting list of 10 patients, the opinions changed: 32.4% approved transplantation, 6.7% didn't approve it, 60.9% were uncertain. A theoretical categorization into deontological or utilitaristic approaches favored the first (41.9% vs 26.7%), with a high prevalence of blank-uncertain (31.5%); 21.9% of the students would change their opinion was that study head of the Transplant Department., Conclusion: Ethical aspects of the medical profession have been discussed with interest by medical school students; the high prevalence of uncertain answers and requests to develop specific tools underline the importance of this educational approach.

Aim: Organ shortage is a rate-limiting factor for transplantation. The aim of this study was to evaluate the impact of an educational program targeted to high school students on opinions concerning organ donation., Methods: Sixteen public high schools in Torino, Italy, were randomized (2001 to 2002) as interventions (n = 8) or controls (n = 8). Intervention was composed of first questionnaire, first lesson (one to two classes; 2 hours, by a trained nephrology fellow); second lesson (all classes together; coordinated by a nephrologist, with patients and trainees); second questionnaire. Control included questionnaires. Statistical analysis compared the opinions in the questionnaires after stratification for age, sex, and type of school., Results: Fourteen schools completed the program (seven interventions: 937 first and 808 second questionnaires; controls: 739 and 659). Television (82.5%) and newspapers (43.2%) were the main sources of information; knowledge on renal transplantation (grafts feasible per patient, average duration) was low; only 12.2% of the students gave correct answers. The opinions on living donation were highly positive (76.8%) with no difference in control, intervention schools, first and second questionnaires, according to sex, age, or type of school. The opinions on cadaveric transplantation were affected by the educational intervention with a drop in negative answers (from 33.7% to 16%), with an increase in positive (from 31.5% to 42.9%) and in uncertain ones (from 34.8% to 41.1%) among the intervention schools; 98% of the students appreciated the program., Conclusion: The positive effect on student opinions suggests the need to develop educational approaches as a part of our routine clinical work.

Living donor transplants (LDtx) represent an underutilized resource in Italy. It is, however, a therapeutic option that deserves greater consideration not only due to the increasing gap between the number of uremic patients on waiting lists (6956) and the number (1464) of cadaveric transplants (CADtx), as evidenced in 2002, but also due to the advantages of LDtx over CADtx. The superiority of LDtx include better graft survival, independent of the donor/recipient relationship, less need for dialytic treatment with preemptive transplants and reduced immunogenicity of the graft due to the brain death-related "cytokine storm." Moreover, some emerging procedures namely laparoscopic nephrectomy instead of open surgery and spiral CT instead of renal angiography namely, reduce the physical and socioeconomic burden of the donor. In the light of these considerations, LDtx should be reconsidered in the Italian scenario of kidney transplantation.

Background: Nephrotic syndrome due to diabetic nephropathy is presently considered an indication for pancreas-kidney transplantation even in the absence of severe renal failure. Reversal of the nephrotic syndrome has been reported, but the mechanisms of this effect are unclear., Aim: To describe the renal morphofunctional pattern and the pattern of proteinuria before and after preemptive pancreas-kidney transplantation., Methods: Methods included quantitative and qualitative assessment of proteinuria as well as renal ultrasound and scintiscan., Case Report: A 42-year-old woman with type 1 diabetes since age 24 had widespread end-organ damage. Renal biopsy (2001) showed a mainly nodular pattern of diabetic nephropathy. Following referral (1999), her serum creatinine ranged from 1.6 to 2.2 mg/dL, with nephrotic range proteinuria (glomerular nonselective, tubular complete). Renal scintiscan revealed bilateral, symmetric, well-perfused kidneys. The functional data before pancreas-kidney graft (February 2003) were: serum creatinine 1.6 mg/dL, creatinine clearance 58 mL/min, serum albumin 2.6 g/dL, proteinuria 9.1 g/d. At hospital discharge (March 2003), the creatinine was 1.2 mg/dL, the creatinine clearance 97 mL/min, the proteinuria 0.676 g/d. Two months later, the creatinine was 1.2 mg/dL and proteinuria 0.421 g/d. A renal scintiscan demonstrated the functional prevalence of the grafted kidney (77% of total function), with vital, almost completely excluded native kidneys (functional contribution, 11.5% each). Proteinuria, ranging from 0.3 to 0.6 g/d, showed a physiological pattern., Conclusions: Functional exclusion of the native kidneys by renal scintiscan gives morphological support to reversal of the nephrotic syndrome.

While the costs of renal transplantation are lower than those of dialysis, little is known about the costs of managing the waiting list. We performed a cost analysis of admission and clinical management of a waiting list for renal and pancreas-kidney transplantation. Admission to the waiting list included (1) renal graft from cadaver: minimum cost Euros () 1784.56 for men < 55 years, maximum 2127.85 for women >/= 55 years; (2) pancreas-kidney transplantation: minimum 2475.50 for men, maximum 2540.10 for women >/= 35 years. Check of suitability state on waiting list after 2 and 5 years: minimum 1400.15 for men >/= 55 years (check every 2 years), maximum 1467.07 for women >/=40, <55 years (every 5 years). The differences are related to the imaging techniques: from 43.90 (Doppler ultrasonography) to 283.28 (coronary angiography). Maintenance of the waiting list: minimum cost 1885.21 in the first year and 3187.02 in the (fifth year) for men < 55 years; maximum 2228.50 (first year) and 5116.70 (fifth year) for women >/= 55 years. These results show different costs for recipients on the basis of sex and age ranges, due to the different requirements for imaging tests such as cardiac scintiscan at age >/= 55 years) and economic charges that increase with age. Reduced waiting times allow lowered total costs. This evaluation allowed us to calculate for our region (Piemonte, Northern Italy), the management costs of the patients presently on our waiting list (369 patients at December 31, 2002) from preparation to transplantation as 959,179.18.

Aim: To evaluate the results of treatment of erectile dysfunction (ED) in kidney transplant recipients before and after the advent of sildenafil., Materials and Methods: From 1981 through 2002, 971 male patients of mean age 53.4 years received a renal graft. Erectile dysfunction (ED) was investigated in all patients at the first urologic visit posttransplantation. Psycho-sexual support was offered to all patients. Before sildenafil use (1998), our diagnostic approach was complex. From 1998 we tested: serum levels of testosterone, prolactin, and glucose with penile duplex ultrasonography and NPT reserved for selected cases., Results: From 1981 through 1998, 365 male kidney transplant recipients (45%) reported ED. Only 169 patients chose to be treated: 27 responded to psycho-sexual therapy; 3 received testosterone with benefit; 133 had a good results from intracavernosal injection of vasoactive drugs; and 6 received a penile prosthesis. Since 1998, 126 patients reported ED (78.3%). Only 78 chose treatment: 24 patients had a satisfactory response to sildenafil (65% with 50 mg and 35% with 100 mg). PGE1 alone or in combination with papaverine and phentolamine produced a good response in 37 patients; 17 patients did not respond to pharmacotherapy; and 5 received a tricomponent penile prosthesis without complications. The side effects of sildenafil and PGE1 therapy were similar to those reported in the literature., Conclusions: ED is an important problem in male renal transplant recipients. Cultural resistance to treatment is common. However, treatment with sildenafil citrate and intracavernosal self-injection of PGE1 are well accepted, and prosthetic devices may help in resistant cases.

Background: Type 1 diabetic patients are a small but challenging subset of chronic kidney disease. The new frontiers of pancreas-kidney transplantation may enhance the need for early referral., Objective: To analyze the referral pattern of type 1 diabetics to a specialized Nephrology Unit, and to quantify the indications for pancreas or pre-emptive pancreas-kidney transplantation at referral in this population., Patients and Methods: Setting of study was a Nephrology Outpatient Unit, dedicated to diabetics, active since 1986; period of study 1991--2002. The main biochemical and clinical parameters were analyzed at referral. Indications for transplantation were put at: serum creatinine (sCr)> or =2 mg/dL or > or =3 mg/dL and/or nephrotic syndrome. Pancreas: lesser degrees of functional impairment without worsening after FK-506 challenge., Results: 90 type 1 diabetics were referred: 48 males, 42 females; median age: 38 (18-65) years; median diabetological follow-up 20 (3-37) years; sCr 1.2 (0.6-7) mg/dL, proteinuria 0.9 (0-12.3) g/day; creatinine clearance: 58 (6-234) ml/min; Hbalc: 8.8% (5.9-14), diastolic blood pressure: 80 (55-100) mmHg, systolic blood pressure: 137.5 (70-180) mmHg. 85.6% had signs of end-organ damage due to diabetes. 67% of the patients had diabetic nephropathy, 20.7% hypertensive with or without diabetic nephropathy. According to the chosen criteria, 30.6% had indications for pancreas-kidney graft (sCr > or = 2 mg/dL), 25.9% considering sCr > or = 3 mg/dL; 28.2% further patients could be considered for isolated pancreas graft., Conclusions: At referral to the nephrologist, over 50% of type 1 diabetics may have indications for pancreas-kidney or pancreas graft; an earlier multidisciplinary work-up is needed to optimize an early pre-emptive transplant approach.

The prognosis of diabetic patients on renal replacement therapy (RRT) is usually poor. We report on the type 1 diabetic woman with the longest RRT follow-up in our area: over 20 years, half on dialysis, half with a renal graft. CS started RRT at age 27 on peritoneal dialysis (3 years), continued until an underdialysis syndrome developed, was switched to acetate dialysis and, because of poor tolerance, to hemofiltration which with good clinical results, allowing her to become the first Italian patient on home hemofiltration, which continued for 5 years. A cadaver graft lasted for the subsequent decade, despite several complications; afterwards she resumed bicarbonate dialysis, choosing a frequent home hemodialysis schedule. Despite several vascular access problems, her clinical conditions were good enough to candidate her for a second renal transplant, performed 3 years ago. This history of active self-care may draw attention to the advantages of a multiple choice dialysis network.

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.