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Introduction: Urinary tract infections (UTI) are the most frequent early and late infectious complications in renal transplant patients. Vesicoureteral reflux (VUR) occurs in more than 86% of renal transplants. It is considered as a possible cause of the onset of complicated urinary tract infections although its actual impact remains uncertain. A therapeutic option in the treatment of VUR, successfully used in particular in pediatric patients, is represented by the injection in the ureter of hyaluronic acid/dextranomer polymers (Dx/HA, Deflux®) performed through the endoscopy procedure. In this study the experience of the Nephrology Unit at the University of Padova is reported. Methods: Six renal transplanted female patients (mean age 45.6 years) who presented a history of recurrent complicated UTIs (more than 3/year), were considered. In these patients a retrograde and voiding cystography documented the presence of VUR at the transplanted kidney. Between February 2016 and July 2018 all these patients underwent endoscopic treatment with Dx/HA. Results: Five patients, after endoscopic treatment with Dx/HA, did not show at the follow up until present any episode of complicated UTIs, confirming the successful of this therapeutic option for the UTI due to VUR in renal transplanted patients. Conclusions: Although based on a limited number of patients, the endoscopic treatment of VUR with hyaluronic acid copolymer Deflux® in kidney transplanted patients is safe, non-invasive, repeatable if necessary, and the results in our patients are favorable. Although considering a period of observation of two years, it might be too short to demonstrate the effectiveness of the treatment in the long-term. However, being able to successfully correct the VUR in kidney transplanted patients represents a very important chance to reduce complicated UTIs in kidney transplanted patients thus increasing the chance for the transplanted organ’s survival.

Background/Aims: In chronic kidney disease (CKD) patients blood pressure variability (BPV) is associated with poor outcome. Sleep disturbances alter BP profiles in hypertensives but their influence on BPV in CKD patients is unknown. We screened a cohort of CKD/ESRD patients to investigate whether sleep quality impacts on BPV. Methods: Consecutive CKD patients' sleep quality was assessed using validated questionnaires (Epworth Sleepiness Scale-ESS); International Restless legs scale-IRLS; Functional Outcomes of Sleep Questionnaire-FOSQ: Insomnia Severity Index-ISI; STOP-Bang). All patients underwent ambulatory blood pressure measurement. Results: 104 out of 143 enrolled patients (78.32% stage-3 CKD; 10.49% Stage-4; 11.19% Stage-5; 6.99% ESRD-under dialysis) completed all the questionnaires. 95.8% were hypertensives, 70% were non-dippers and 27.8% had resistant hypertension. STOP-Bang>4 proved sleep disorders in 84.84% of patients. Patients with IRLS>10 had greater diastolic nocturnal standard deviation (DNSD) and a trend (p=0.05) for systolic nocturnal SD (SNSD). Patients with ISI>14 had greater SNSD and in 28.8% FOSQ showed severely impaired sleep quality. Their systolic nocturnal BPV was significantly greater. ISI was independently associated with SNSD. FOSQ and diastolic nocturnal BPV were negatively correlated at the bivariate analysis and FOSQ independently predicts systolic nocturnal BPV at multivariate regression analysis. Conclusions: In CKD patients impaired sleep quality increases BPV, might contribute to their disease progression and worsen prognosis. Searching for sleep problems in CKD patients could help planning their treatment of sleep problems contributing to CV risk reduction. Our data provide the rationale working hypothesis for the need of studies with larger number of patients aimed to demonstrate improved outcome of CKD progression and CV risk with the treatment also of sleep disorders.

Atherosclerotic renal artery stenosis can cause ischaemic nephropathy and arterial hypertension. We herein review the observational and randomized clinical trials (RCTs) comparing medical and endovascular treatment for control of hypertension and renal function preservation. Using the Population Intervention Comparison Outcome (PICO) strategy, we identified the relevant studies and performed a novel meta-analysis of all RCTs to determine the efficacy and safety of endovascular treatment when compared with medical therapy. The following outcomes were examined: baseline follow-up difference in mean systolic and diastolic blood pressure (BP), serum creatinine, number of drugs at follow-up, incident events (heart failure, stroke, and worsening renal function), mortality, cumulative relative risk of heart failure, stroke, and worsening renal function. Seven studies comprising a total of 2155 patients (1741 available at follow-up) were considered, including the recently reported CORAL Study. Compared with baseline, diastolic BP fell more at follow-up in patients in the endovascular than in the medical treatment arm (standard difference in means -0.21, 95% confidence interval (CI): -0.342 to -0.078, P = 0.002) despite a greater reduction in the mean number of antihypertensive drugs (standard difference in means -0.201, 95% CI: -0.302 to -0.1, P < 0.001). At variance, follow-up changes (from baseline) of systolic BP, serum creatinine, and incident cardiovascular event rates did not differ between treatment arms. Thus, patients with atherosclerotic renal artery stenosis receiving endovascular treatment required less anti-antihypertensive drugs at follow-up than those medically treated. Notwithstanding this, they evidenced a better control of diastolic BP.

Absolute blood pressure (BP) values are not the only causes of adverse cardiovascular consequences. BP variability (BPV) has also been demonstrated to be a predictor of mortality for cardiovascular events; however, its determinants are still unknown. This study considers 426 subjects with ambulatory BP monitoring (ABPM) measuring 24-h, diurnal and nocturnal absolute BP values and their standard deviations of the mean, along with nocturnal fall, age, sex and current treatment. Patients were divided in two subgroups, controlled and uncontrolled BP, and BPV of patients with "true" and "false" resistant hypertension was also analyzed. Nocturnal and 24-h BPV were higher in the group with uncontrolled hypertension. Multiple regression analysis showed that absolute BP, age, nocturnal fall, but not sex predicted BPV. Patients with "true" resistant hypertension had greater BPV than "false" resistant hypertension patients. Absolute BP resulted as the main determinant of 24-h and nocturnal BPV but not daytime BPV. Also nocturnal BP fall and age resulted as predictors of BPV in treated and untreated patients. Patients with "true" resistant hypertension have a higher BPV, suggesting a higher sympathetic activation. Evidence is still limited regarding the importance of short-term BPV as a prognostic factor and assessment of BPV cannot yet represent a parameter for routine use in clinical practice. Future prospective trials are necessary to define which targets of BPV can be achieved with antihypertensive drugs and whether treatment-induced reduction in BPV is accompanied by a corresponding reduction in cardiovascular events.

Pelvic-ureteric junction obstruction (PUJO) is rare in adults and may be seen when the diagnosis has been missed in childhood. Hypertension may be a feature of PUJO but limited data are currently available in literature to support its association. We report a case of a 29-year-old woman who presented with severe hypertension. Work-up to exclude secondary hypertension showed high plasma renin activity, and imaging by ultrasound and computerized tomography a hydronephrosis and PUJO with impairment of kidney drainage at the renal scintigraphy. After double-J ureteric stenting, blood pressure decreased, antihypertensive medication tapered and the patients was normotensive with no antihypertensive medications after 6 months. We provide an update of the pathophysiology of hypertension in PUJO and a review of the available literature in order better to define the available treatments for these patients.