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Introdução: O efeito da circuncisão sobre a função sexual masculina é controverso, podendo ter efeitos positivos ou negativos em vários domínios da sexualidade (função erétil, ejaculação, orgasmo, desejo). O objetivo foi avaliar o efeito da circuncisão na função sexual. Métodos: Amostra composta por todos os doentes circuncisados pelo mesmo cirurgião (investigador principal) nos últimos 26 meses, com idade inferior a 60 anos e com atividade sexual nos 30 dias prévios às entrevistas. Para avaliação da função sexual pré e pós-circuncisão foram usados os questionários International Index of Erectile Function-5 (IIEF-5) e o Brief Male Sexual Function Inventory (BMSFI), sendo que os dados pré-circuncisão foram obtidos de forma retrospetiva. Foram ainda questionados o motivo da circuncisão, o tempo de latência intravaginal e o grau de satisfação dos doentes com o procedimento. Resultados: Amostra composta por 25 doentes, idade média de 36,3±10,3 anos (lim: 22-55), sendo a avaliação realizada em média 11,4±5,4 meses após a cirurgia (lim: 5-26). Dos indivíduos avaliados, 52.0% referiram melhoria da vida sexual, 44,0% não notaram diferença e 4,0% referiram agravamento. Repetiriam a cirurgia 92,0% dos indivíduos.Não existiram diferenças estatisticamente significativas entre os resultados pré-circuncisão e pós-circuncisão em relação ao IELT (p=0,608), satisfação sexual “subjetiva” (p=0,130), score total do BMFSI (p=0.054) e score do IIEF-5 (p=0,351).Há uma correlação entre os scores BMFSI pré-circuncisão e pós-circuncisão e os scores IIEF-5 pré e pós-circuncisão, respetivamente (p

Introduction: Non-muscle invasive (NMI) bladder cancers (BC) account for 75% of BC cases, and most are initially diagnosed and treated with transurethral resection of bladder tumor (TURB). After primary TURB, a repeat resection (rTURB) should be carried out in cases of incomplete resection; however, rTURB is recommended by EAU guidelines in pT1 tumors even when the completeness of the original resection is believed by the surgeon, with reported rates of residual tumor in up to 33%-55% and upstaging in up to 25%. Since the quality of initial resection impacts in the result of a rTURB, these rates are largely dependent on the primary treatment and accurate prediction of completeness, with a probable high variability between surgeons and Centres. Our objectives to determine whether rTURB after initial perceived complete resection would frequently identify residual tumor and if this procedure would improve outcomes in NMIBC patients. Methods: Patients submitted to TURB from 2015 to 2017 were analysed, identifying which underwent rTURB after initial resection without follow-up cystoscopy in between. Primary perception of completeness, stage and grade were correlated with the eventual presence, stage and grade of residual tumor. Results: We analyzed 546 TURB procedures; of these, 275 (50.4%) were for primary bladder cancer. pT1 lesions were found in 85 (30.9%) of primary TURBs; 12 of these were selected for rTURB due to incomplete resection. Of the remaining 73 macros- copically completely resected primary pT1 tumors, 26 (30.6%) underwent elective rTURB. Repeat TURB after complete resection of primary pT1 tumors yielded residual tumor in 11.5% of patients (n= 3). All patients with residual tumor had primary pT1 high grade lesions; no upstaging or upgrading was observed. Patients had similar recurrence rates at 1-year regardless of rTURB. Discussion/Conclusion: Standard practice in primary TURB pro- cedures varies across surgeons and centers and will reflect on residual tumor rates. Indications for rTURB might not be suitable for all patients, and single Centre results should be taken in consideration when selecting patients for rTURB.

Introdução: Com a evolução e melhoria da técnica cirúrgica e dos cuidados médicos de suporte, a esperança média de vida dos doentes aumentou, pelo que aspetos como a qualidade de vida após cirurgia têm sido cada vez mais valorizados. A resseção anterior do reto (RAR) é uma opção terapêutica para doentes com certas patologias localizadas ao reto (como adenocarcinoma). Esta técnica tem potencial de acarretar importantes morbilidades pós cirúrgicas, não só gastrointestinais, mas também urológicas, como incontinência e disfunção erétil. O objetivo foi avaliar o impacto na função erétil e sexual de doentes submetidos a RAR. Material e Métodos: Estudo transversal, que incluiu todos os doentes do sexo masculino submetidos a RAR entre novembro de 2018 e setembro 2019 no Centro Hospitalar e Universitário de Coimbra (CHUC) (n=43). A população apresentou uma média de idade de 66,1±9,9 anos (idades compreendidas entre 29 e 90). Foram realizadas entrevistas telefónicas e foi efetuado um questionário acerca da sexualidade e função erétil prévios à cirurgia, bem como após a mesma. Para este fim, foi utilizado o Index Internacional da Função Erétil Simplificado (IIEF-5) com um cut-off de pontuação

OBJECTIVES Tacrolimus has a narrow therapeutic window, and lack of adherence to the therapeutic regimen is a main risk factor for acute graft rejection; hence, the prolonged-release formulation was created. A high intrapatient variability for tacrolimus trough levels has been associated with worse graft outcomes; therefore, we investigated the correlation between the tacrolimus variation coefficient and the development of biopsy-proven acute graft rejection in kidney transplant patients with typical maintenance immunosuppression versus the prolonged-release formulation. MATERIALS AND METHODS This was a single-center observational retrospective study that included all adult kidney transplants from deceased donors between January 2011 and December 2014 for which the transplant recipients were given maintenance therapy with tacrolimus prolonged-release formulation (Advagraf). The overall tacrolimus variation coefficient was calculated for the follow-up period from transplant until December 2019. Biopsy-proven acute graft rejection results were collected throughout follow-up. Statistical analysis was performed with SPSS software. RESULTS The study was composed of 147 patients with a mean follow-up time of 60.4 ± 15 months. The mean age of the patients was 47.5 ± 11.9 years and 67.3% were men. Of these 147 patients, 29 had at least 1 episode of acute graft rejection during follow-up. There was a significant correlation between patients with a higher tacrolimus variation coefficient and the presence of biopsy-proven acute graft rejection. Receiver operating characteristic curves were used to determine an intrapatient variability cutoff point of 28.3% for tacrolimus. Younger patients were also more likely than older patients to develop acute graft rejection in our sample. CONCLUSIONS High intrapatient variability of tacrolimus trough levels is a risk factor for acute graft rejection in kidney transplant patients.

João P Lima,1 João Carvalho,1 Vasco Quaresma,1 Edgar Tavares-da-Silva,1 Rodolfo Silva,2 Paulo Azinhais,2 Gracinda Costa,2 Arnaldo Figueiredo1 1Urology and Renal Transplantation Department, Coimbra University Hospital Center, Coimbra, Portugal; 2Nuclear Medicine Department, Coimbra University Hospital Centre, Coimbra, PortugalCorrespondence: João P LimaUrology and Renal Transplantation Department, Coimbra University Hospital Center, Praceta R. Prof. Mota Pinto, Coimbra, 3004-561, PortugalEmail joaopedrosolima@gmail.comBackground: Recommended imaging modalities for prostate cancer staging have disappointing sensitivities, whereas [68Ga]-PSMA PET/CT (PET-PSMA) shows promising sensitivities and specificities in the initial management of prostate cancer. Recent studies have revealed that a significant change of management when PET-PSMA was used, with favorable negative predictive values.Methods: In this retrospective study, we analyzed every PET-PSMA performed in our center for initial staging of intermediate and high-risk prostate cancer. Patients were divided into two groups based on whether imaging modalities other than PET-PSMA were performed. In patients submitted to radical prostatectomy, PET-PSMA findings were compared to histological analysis of the specimen.Results: PET-PSMA results of 57 patients were gathered, with 77.2% (n=44) having performed CT scan or bone scan (BS) prior to PET-PSMA. Prostate cancer management strategy was changed in 61.4% (n=27), when PET-PSMA was performed following CT and BS. BS and CT results were consistent with PET-PSMA in 43.2% and 44.8%, respectively. In 30 cases, a curative strategy was used based on PET-PSMA findings. PET-PSMA revealed a negative predictive value of 95.2% in 23 patients submitted to radical prostatectomy with bilateral pelvic lymphadenectomy. Prostate SUV values on preoperative PET-PSMA correlated with initial PSA, ISUP grade, PC risk staging and presence of extraprostatic lesions.Conclusions: PET-PSMA is a key element for prostate cancer staging and management, with high diagnostic accuracy. More prospective studies need to be implemented to determine its role as a first-line staging tool.Keywords: PET-CT, prostate cancer, specificity and sensitivity, metastasis, lymphatic metastases, bone metastases

Background Benign prostatic hyperplasia (BPH) is common in older adults. Although BPH may be asymptomatic in patients with chronic kidney disease (CKD) with low diuresis, the condition may become troublesome when diuresis resumes after transplantation. This study evaluated the effect that developing acute urinary retention (AUR) in first 4 months after kidney transplantation (KT) can have on graft function at 6 months. The study identified predictive factors and analyzed treatment of AUR in these patients. Methods This study retrospectively included 303 men who received KT. Independent samples Student t test was used to compare glomerular filtration rates (GFRs) at 6 months. Logistic regression was applied to identify predictors of AUR. Results The study found that 14 patients developed AUR within the first 4 months after KT. This group had lower GFR at 6 months post-KT. Nine patients required transurethral resection of the prostate, and 2 of these patients developed acute graft pyelonephritis following resection. Residual diuresis and recipient age were predictive factors. Recipient age >55 years was a risk factor. Medical therapy of BPH before transplantation was a protective factor. Conclusions Developing AUR in the first 4 months after KT was associated with lower graft GFR at 6 months, and transurethral resection of the prostate was required in 64% of these patients, with good results. Medical therapy for BPH before the transplant was associated with a lower risk of AUR. Older patients and patients with pretransplant low urine output had a higher risk of AUR. These patients should be closely monitored in the posttransplant period for the presence of obstructive uropathy.

Background Borderline changes suspicious for acute T-cell–mediated rejection (BC) are frequently seen on biopsy specimens, but their clinical significance and clinical management are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy-proven BC vs acute T-cell–mediated rejection (aTCMR) and the influence of treating BC on graft outcomes. Methods A retrospective cohort study was performed in all kidney transplant recipients with biopsy-proven BC and aTCMR between January 2012 and December 2018, according to Banff 2017 criteria; patients with concomitant antibody-mediated rejection were excluded. Results We included 85 patients, 30 with BC (35.3%) and 55 with aTCMR (64.7%). There was no difference between groups regarding demographics, HLA matching and sensitization, immunosuppression, or time of transplant. Treatment with steroids was started in 15 patients with BC (50%) and in all patients with aTCMR, with 4 of the latter additionally receiving thymoglobulin (7.2%). At 1 year post biopsy, overall graft survival was 71%, and despite presenting better estimated glomerular filtration rate (eGFR) at biopsy (33.3 ± 23.4 vs 19.9 ± 13.2 mL/min/1.73 m2, P = .008), patients in the BC group presented the same graft survival as the aTCMR group according to Kaplan-Meyer survival curves. When analyzing the BC group (n = 30) and comparing the patients who were treated (n = 15) vs a conservative approach (n = 15), graft survival at 1 year was 87% for treated patients and 73% for nontreated patients (P = .651), with no difference in eGFR for patients with functioning graft. However, at longer follow-up, survival curves showed a trend for better graft survival in treated patients (70.2 ± 9.2 vs 38.4 ± 8.4 months, P = .087). Conclusion Our study showed that patients with BC did not present better graft survival or graft function at 1 year after biopsy or at follow-up compared with the aTCMR group, despite better eGFR at diagnosis. We found a trend for better graft survival in patients with BC treated with steroids compared with a conservative approach. These results reinforce the importance of borderline changes in graft outcomes and that the decision to treat can influence long-term outcomes.

An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.

Prostate carcinoma is a highly prevalent biologically and clinically diverse disease, generally associated with a consistent elevation of prostate-specific antigen levels. Castration-resistant prostate cancer represents a heterogeneous clinical setting that ranges from patients with an asymptomatic prostate-specific antigen elevation after hormone blockade failure and good performance status to patients with significant debilitating symptoms and rapidly progressive disease, leading to death. Nonmetastatic castration-resistant prostate cancer is a transient disease stage defined over specific criteria established within a sensitive time period. The majority of the patients with nonmetastatic castration-resistant prostate cancer will eventually develop metastatic lesions, associated with prostate cancer-specific morbidity and mortality. However, progression to metastatic disease is a heterogeneous process still not fully understood, with studies suggesting that younger age, high Gleason score ( 7), high prostate-specific antigen levels, reduced prostate-specific antigen doubling time ( 6 months), and a rapid alkaline phosphatase rise as potentially associated factors. Although the nonmetastatic castration-resistant prostate cancer treatment landscape has substantially evolved in recent years, the disease heterogeneity makes treatment decisions for this population challenging in the effort to achieve a balance between the risk of disease progression and the toxicity of new treatments in patients who often have associated comorbidities, yet are generally asymptomatic. The present article addresses the current main challenges in nonmetastatic castration-resistant prostate cancer management, including in diagnosis, owing to the development of new imaging modalities with a direct impact in disease detection, prognostic classification, as a result of the traditionally oversimplified definition of disease aggressiveness (mainly based on prostate-specific antigen doubling time), and patient selection for the most adequate treatment.

De Novo nephrolithiasis in renal transplant can have severe consequences since renal transplantation involves a single functioning kidney with medical and anatomical specificities (heterotopic transplantation on iliac vessels, immunosuppressive treatments, and comorbidities).To systematically review all available evidence on the prevalence of de novo nephrolithiasis in renal transplant, presentation, and stone characteristics, and to report in a meta-analysis the efficacy of stone treatments (extracorporeal shock wave lithotripsy [ESWL], medical treatment, percutaneous nephrolithotomy [PCNL], open surgery, and ureteroscopy).Medline, Embase, and the Cochrane Library were searched up to November 2021 for all relevant publications reporting the management of de novo nephrolithiasis in renal allografts. The primary outcome was stone-free rate (SFR) at 3 mo. Secondary outcomes included prevalence, stone characteristics (size, density, and composition), symptoms on presentation, need for drainage, complications, and recurrence. Data were narratively synthesized in light of methodological and clinical heterogeneity, and a meta-analysis was performed for SFR. The risk of bias of each included study was assessed.We included 37 retrospective studies with 553 patients and 612 procedures; of the 612 procedures 20 were antegrade ureteroscopy, 154 retrograde ureteroscopy, 118 PCNL, 25 open surgery, 155 ESWL, and 140 surveillance/medical treatment. The prevalence of nephrolithiasis in renal transplant was 1.0%. The mean stone size on diagnosis was 11 mm (2-50). The overall SFR at 3 mo was 82%: 96% with open surgery, 95% with antegrade ureteroscopy, 86% with PCNL, 81% with retrograde ureteroscopy, and 75% with ESWL.De novo nephrolithiasis in renal transplant is an infrequent condition. A high SFR were obtained with an antegrade approach (ureteroscopy, PCNL, and open approach) that should be considered in renal transplant patients owing to the heterotopic position of the renal graft. The choice of technique was correlated with stone size: generally ureteroscopy and ESWL for stones 11-12 mm (mean stone size) versus PCNL and open surgery for 17-25 mm stones.De novo nephrolithiasis in renal transplants is an infrequent situation that can have severe consequences on the function of the renal graft. We evaluated the efficacy of each treatment and noted that antegrade approaches (open surgery, percutaneous nephrolithotomy, and antegrade ureteroscopy) were associated with the highest stone-free rate. As opposed to the management of nephrolithiasis in native kidney, an antegrade approach should be considered more in renal transplant patients.

Annually, about 500 kidneys are transplanted in Portugal. Despite some studies looking into the procurement biopsies' benefits (like the potential of predicting long term results and establishing a baseline), few have studied its risks, especially in the period between the harvest and the transplant.A cross-sectional study, including all patients who received a kidney graft between the 2019 and 2020 at the University Hospital of Coimbra (n = 203). Biopsies were done using a polar double core puncture technique with 18-gauge needles.Fifty-six patients (27.6%) received a biopsied graft. The median postoperative hemoglobin fall was 2.8 g/dL; this fall was more pronounced in the group that received a biopsied kidney (3.2 g/dL vs 2.6 g/dL; P.05). The number of transfusions needed during the hospital stay (2.2 U vs 1.3 U; P.05) and the median length of stay (13.2 ± 8.4 vs 10.6 ± 5.8, P.05) were greater in the biopsied group. Patients who received a biopsied kidney were older (median age of 57.3 vs 46.9). Cold ischemia time was greater in the biopsied group (19 hours vs 15.2 hours; P.05). However, we did not find a relation between the age and the hemoglobin drop or blood transfusions. At discharge, renal function was not statistically different between the 2 groups (P was nonsignificant).Despite the biopsies' potential advantages, they are not without risks. This study showed a statistical association between harvest biopsies and higher risks of hemorrhage, regardless of age. When needed, procurement biopsies seemed safe for the recipients, but at the expense of increased patient surveillance and resource consumption.

Living donor kidney transplant represents the best treatment option for patients with end-stage kidney disease; however, it has been associated with possible risks to the donor. Our aim was to evaluate the impact of kidney donation in the donor's estimated glomerular filtration rate (eGFR), blood pressure, and proteinuria and related risk factors.A single-center, retrospective study, including all living donors who underwent nephrectomy between January 2000 and December 2019, was performed. Demographic, clinical, and laboratory data were collected. Risk factors for a decrease in eGFR30 mL/min/1.73 mEighty-six donors were included with a mean age of 46.7 ± 9.07 years. The mean follow-up was 105.6 ± 65.4 months, and 35 patients (41%) had more than 10 years of follow-up. No significant difference was found in proteinuria or body mass index (P.1) before and after the donation. The prevalence of hypertension was higher after kidney donation (9.3% vs 22.1%; P.001). A mean reduction in the eGFR in the first year of 37 ± 12 mL/min/1.73 mLiving donor nephrectomy appears to be an acceptably safe intervention. Predonation eGFR influences the adaptative response after nephrectomy; however, other variables did not have an impact on long-term outcome in our population.

Hepatitis E virus (HEV) is a cause of significant morbidity and mortality, representing an important global public health problem. Immunocompetent patients with acute hepatitis E can clear the infection spontaneously; however, in approximately two thirds of cases, immunosuppressed patients, such as kidney transplant (KT) recipients, fail to clear the HEV infection and develop chronic hepatitis.We report 3 cases of HEV infection in KT patients. Two presented only with laboratory abnormalities and elevated liver enzymes, and 1 presented with symptomatic disease motivating hospital admission. None was able to clear the infection spontaneously, and they were all treated with ribavirin, accompanied with reduction of immunosuppressive drugs. Adverse effects of the treatment were reported in 2 patients, and in 1 case, a dose reduction was necessary. All patients responded to the treatment and have no current evidence of active disease. No alterations of basal kidney function during or related to the treatment were registered.HEV screening in KT patients presenting with abnormal liver function of undetermined cause is fundamental, as it might have poorer outcomes in this specific population. The treatment with ribavirin seems to be safe and effective, although we must always be alert to potential side effects, maintaining a close follow-up of these patients.

Kidney retransplant outcomes in the elderly are not well established. Our aim was to compare major clinical outcomes between patients older and younger than 60 years old at retransplant and between first and second kidney transplant (KT) for recipients older than 60 years old.We performed a retrospective, longitudinal study that included all patients who underwent KT between January 2008 and December 2019. We defined 3 groups according to recipient age and retransplant status: group 1, patients ≥60 years old and retransplant; group 2, patients60 years old and retransplant; group 3, patients ≥60 years old and first kidney transplant. We compared clinical outcomes such as acute rejection, death-censored graft survival, and patient survival between groups.We included 109 patients with a second KT, including 13 older than 60 years old (group 1) and 96 younger than 60 years old (group 2). There were no differences in death-censored graft survival or patient survival. There were no biopsy-proven acute rejections for older patients compared with 21 events in the younger group. Regarding differences between retransplant (group 1, n = 13) and first kidney transplant (group 3, n = 390) in patients older than 60 years old, there were no differences in death-censored graft survival at 1 and 5 years or in patient survival.In our study, major clinical outcomes of retransplant in the elderly were similar to those of their younger counterparts with a second graft and with those of older patients with a first graft.

Despite progressive improvements in graft and patient survival after kidney transplantation over the last decades, an increasing number of patients are waitlisted for retransplantation. Identifying the risk factors for second graft failure can help us improve management for such patients. The aim of this study was to compare the outcomes of kidney retransplantation with those of first transplantation.This retrospective study included all the recipients of a second kidney transplant between January 2008 and December 2019. For each patient with a second kidney transplant, we selected the paired recipient from the same donor. We excluded recipients of donations from living donors, patient-and-donor pairs with more than 1 transplant, and patients without a pair. The follow-up took place December 31, 2020. We included 152 patients, corresponding to 76 pairs of recipients.Patients who underwent a second transplant had significantly higher panel reactive antibody values and longer waiting time for retransplantation. Biopsy-proven acute rejection episodes were doubled in patients undergoing a second transplant (P = .12). There was a lower survival of second grafts at the first, fifth, and 10th year (P.05). The main factor influencing graft loss for both groups was acute rejection, and, in patients, with a second transplant, acute rejection increased the risk of graft loss by 17 times (odds ratio, 17.5; 95% confidence interval, 4.19-98).The clinical results of second kidney transplants still fall short of first transplants, with the main factor of poor prognosis being acute rejection. In young patients, allocation and immunosuppression management should consider this risk to improve long-term outcomes.

Vaccination is a promising strategy to control the ongoing pandemic; however, solid organ recipients tend to develop a weaker immune response to vaccination. Anti-spike SARS-CoV-2 antibodies titers were measured 2-4 weeks post-vaccination completion in 131 KT patients without previous infection. Demographic, clinical, and laboratorial parameters were analyzed to identify which factors contributed to seroconversion. Factors that influenced seroconversion, that occurred in 76 patients (58%), were longer time post-transplant, immunosuppression without an antiproliferative drug and vaccination with mRNA vaccines. Patients who received mRNA vaccines had significantly higher rates of seroconversion compared with adenovirus vector vaccines (67% vs 33%, P .001) and higher anti-spike IgG titers. These findings reinforce the need to discuss the vaccination strategy in this population, including a third dose with a mRNA vaccine.

Background: Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation. Objective: To develop a prediction model for urinary tract cancer in patients referred with haematuria. Design, setting, and participants: A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded. Outcome measurements and statistical analysis: The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism. Results and limitations: The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy. Conclusions: This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation. Patient summary: We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.

Atypical hemolytic uremic syndrome (aHUS) is one of the most challenging diseases for a nephrologist, with high rates of progression to end- -stage kidney disease (ESKD) and post-transplant recurrence. Complement dysregulation has been found in up to 70% of cases, which can be hereditary or acquired. Over the last few years, knowledge of the pathogenesis of aHUS has greatly increased, with the unravelling of the complement’s role, providing not only the chance for individualized post-transplant recurrence risk assessment, but also the possibility of a highly effective treatment through pharmacological C5-9 blockade with eculizumab. The overall outcome and prognosis of patients with aHUS has dramatically improved since the approval of this drug in 2011, allowing renal transplant to be a much safer option for these patients. Our aim was to present a proposal for the management of patients with aHUS, candidates for renal transplantation, in the light of the most recent studies.

Introduction:Angiosarcomas are rare tumors, comprising less than 1% of all sarcomas. However, they portend a poor prognosis, as they tend to metastasize early, being of uttermost importance a prompt diagnosis and treatment.Case description:We present the case of a 55-year-old female with history of kidney transplantation, immunosuppressed with tacrolimus, prednisolone, and mofetil mycophenolate. Fifteen years after the transplant, she developed an ulcerated lesion on the site of a nonfunctioning arteriovenous graft, which was excised. Histology was compatible with a high grade angiosarcoma that invaded the margins, and immunosuppression was switched to everolimus. Staging imaging exams revealed lymph node, muscle, and lung metastases. Shortly after, nodular lesions appeared compatible with local recurrence of the disease, and the patient showed severe deterioration of her clinical condition, being proposed for palliative chemotherapy. However, the disease showed an explosive progression and the patient died before starting the treatment.Conclusion:This case emphasizes the importance of including inspection of the vascular access (functioning or not) in regular post-transplant consultation and value any alterations in the attempt of a timely diagnosis. Although rare, angiosarcoma is an important entity that should be considered in the differential diagnosis of soft tissue masses arising from a vascular access, especially in immunocompromised patients. Aggressive treatment should be offered whenever possible.

Introduction Chronic kidney disease in the pediatric population is associated with numerous comorbidities and an increased risk of mortality. Kidney transplantation (KT) is considered to be the option of choice in children with end-stage renal disease. Aim To characterize a single center experience in pediatric KT in the last 35 years. Methods A retrospective analysis of epidemiologic and clinical data from KT pediatric patients from January 1981 to December 2016. For outcome analysis, cases were divided into decades (1981–89; 1990–99; 2000–09; 2010–16). Results One hundred and 4 children (KT mean age 13.7 ± 3.32 years; 57.7% male) underwent 111 renal transplants (13% with living donors). Congenital anomalies of the kidney and urinary tract (36.5%) and glomerular disease (29%) were the major causes of renal disease. Peritoneal dialysis was the predominant initial therapeutic modality in 69 children (62.2%). Mean dialysis time was 19.2 months, 9 patients (8.1%) having had preemptive KT. Median follow-up was 181 months. Uncensored graft survivals rates at 5, 10, 15, and 20 years were 79.7%, 74.3%, 59.5%, and 52.8%, respectively. Graft survival improved significantly over the decades (P = .03). Higher estimated glomerular filtration rate measured at 1 year, induction immunosuppressive therapy use (thymoglobulin/basiliximab), and lower incidence of acute rejection rates were associated with superior graft survival (P Conclusions Uronephropathies were the most frequent cause of renal failure and peritoneal dialysis, which was the main renal replacement therapy according to the literature. Graft survival improved significantly over the study period; we hypothesize that this was related to surgical advances and the use of more effective immunosuppressive drugs.

Obturator hernia is an extremely rare type of hernia and an uncommon cause of intestinal obstruction. Diagnosing it represents a challenge due to the lack of specific signs and symptoms. The delay in establishing the diagnosis is responsible for its high rate of mortality. The patients are usually older, emaciated, small women. We presented a case of a small, thin, 88-year-old woman that came to our emergency department with a four-day history of lower abdominal pain, more intense in the left iliac fossa associated with anorexia and constipation. The diagnosis of the left obturator hernia was made intra-operatively. The small bowel, inside the obturator foramen, was necrotic so we made an enterotomy with primary repair of the hernia defect. The patient had post-operative ileus and left inguinal seroma. She was discharged on day 15 post-op with a good recovery. This case report is meant to be an alert for the difficulty of the obturated hernia diagnosis.