P1688THE IMPACT OF KIDNEY DONOR PROFILE INDEX (KDPI) AND KIDNEY DONOR RISK INDEX (KDRI) ON KIDNEY TRANSPLANT FUNCTION: A MONOCENTRIC ANALYSIS AFTER ONE YEAR OF FOLLOW UP

Background and Aims

Evaluation of kidney donors is a complex process based on the elaboration of clinical, laboratory and imaging data.

Until 2014, the quality of kidney transplant (KTx) was assessed considering standard donation criteria (SCD) or extended donation criteria (ECD).

ECD kidneys (kECD) defined subjects older than 65 years without comorbidities or younger, but with comorbidities, such as hypertension, cerebral stroke, high creatinine level (above 1.5 mg/dL).

The Kidney Donor Risk Index (KDRI) is an estimate of the relative risk of post-transplant kidney graft failure from a particular deceased donor compared to a reference donor.

The value obtained is than converted in a percentage called KDPI (KDPI ≥85% is considered as similar of a kidney from ECD), which represent the percentage of utilized donor in the last year better than the considered.

Italian experience in Donor Cardiac Death (DCD) is growing and doubled last KTx year, reaching 1.1 pmp in 2018, with the 22.5% of donors procured at our center.

Our DCD KTx protocol has been active since November 2017, with promising results. We considered only controlled DCD (cDCD) Maastricht Class III.

Methods

We compared all DCD and DBD KTx performed in the Nephrology Unit of the University Hospital of Modena, Italy, from November 2017 to December 2018. We excluded living donor transplantation and combined liver–kidney transplantation. In this study, only cDCD are considered.

We studied KDPI and KDRI score for both DBD and DCD KTx .

Comparison between data from DCD and DBD was performed with t – Student and Chi Square test, survival analysis according to Kaplan-Meier and a Pearson correlation between KPI-KDRI and one year graft function was elaborated.

ROC curve analysis was performed for KDPI – KDRI and DGF for both groups.

A p lower than 0.05 was considered significant.

Results

A total of 28 DBD KTx, 18 double (64.3%) and 10 single (35.7%) and 7 DCD KTx, 3 double (42.8%) and 4 single (57.2%) were observed during the study. Donors and recipients clinical and immunological characteristics are reported in table1.

All of DCD and 64.3% of DBD donors underwent kidney biopsy (Karpinski values are reported in table 1).

Induction therapy was with aTG in DCD KTx and ECD DBD KTx and with anti-interleukin-2 receptor monoclonal antibodies in SCD DBD KTx. Maintenance immunosuppression consisted in steroid, tacrolimus and mycophenolic acid.

KTx outcomes were reported in table 1 with no differences in both groups between creatinine (p0.3) and eGFR (p0.25).

We analyzed KDPI and KDRI values from DBD and DCD KTx and we stratified them as reported in table 2.

We found 7 DGF in DBD KTx (85% with KDPI >85% and KDRI >1.5) and only 1 DGF in DCD KTx with KDPI>85% and KDRI > 1.5.

We did not find a statistical correlation between KDPI- KDRI and eGFR in both DBD KTx (2 patients died and 3 patients were lost at follow up) (r -0.32, p 0.13; r -0.26, p 0.22) and DCD KTx (r -0.59, p 0.15; r -0.47, p 0.28). (Figure 1)

We performed a ROC curve Analysis to investigate the role of KDPI – KDRI and the risk of DGF. We found no statistical correlation in DCD KTx, considering the small sample size (p 0.61) but we found a significant statistical value in DBD KTx (p 0.03 – p 0.02 with a AUC of 0.77-0.78).

Survival analysis did not show statistical difference between DBD and DCD (p 0.72), no graft loss in the first year, although two DBD (92.8%) recipients died (1circulatory arrest,1 sepsis), no one died in DCD group.

Conclusion

cDCD is a valid resource for KTx, with similar outcomes to DBD. This remarks the importance of a multidisciplinary team and a correct selection of donors. We did not find a correlation between KDPI-KDRI and KTX function after one year of follow up in our population for either group.

P0494UNUSUAL CASE OF ACUTE KIDNEY INJURY (HISTOLOGICAL EVALUATION: COLLAPSING GLOMERULOPATHY) IN HEMOPHAGOCYTIC SYNDROME ASSOCIATED WITH NK/T LYMPHOMA

Background and Aims

Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome induced by aberrantly activated macrophages and cytotoxic T cells. The primary (genetic) form, caused by mutations affecting lymphocyte cytotoxicity and immune regulation, is most common in children, whereas the secondary (acquired) form is most frequent in adults. Secondary HLH is commonly triggered by infections or malignancies but may also be induced by autoinflammatory/autoimmune disorders, in which case it is called macrophage activation syndrome.

The diagnosis of HLH in adults should be based on the HLH-2004 diagnostic criteria in conjunction with clinical judgment and the patient’s history.

Renal involvement has previously been reported in 24 adult cases, mostly as acute renal failure. Collapsing glomerulopathy is extremely rare with only six previous cases reported in the literature.

Case presentation We report the case of an African man, 31 years old, presented with fever, acute kidney injury: serum creatinine 10.3 mg/dl; urine protein 600 mg/dl, macrohematuria, ANA/ANCA were negative, low serum C3, organomegaly, anemia, thrombocytopenia, hypertriglyceridemia, hypofibrinogenemia, hyperferritinemia, direct and indirect antiglobulin (Coombs) tests were negative, low haptoglobin; elevated LDH; normal partial thromboplatin time. Peripheral blood smear examination reveal few schistocytes. ADAMTS13 activity was found to be 25%. HBV-DNA and HIV were negative. Anticardiolipin antibodies were negative. Lab exam suggested the relapse of an EBV infection and primary mycoplasma infection. Because of uremic symptoms and persisting oliguria we started replacement therapy by hemodialysis. Plasmapheresis was started because of suspected thrombotic microangiopathy. Suprisingly the kidney biopsy was consistent with collapsing glomerulopathy with evidence of tubular injury while the bone marrow biopsy diagnosed an EBV NK/T-Cell lymphoma.

During the course of his hospitalization, the patient suffered high fever. C-reactive protein, WBC and procalcitonin levels were elevated. Antimicrobial agents were initiated, starting with ceftriaxone then upgraded to piperacillin/tazobactam and then the shifted to teicoplanin and meropenem.

Blood, urine and stool cultures were negative.VRE positive, IgM Mycoplasma pneumoniae were positive; EBV PCR on bone marrow blood was positive. Malaria screening was negative. The antibiotic therapy was finally switched to doxycycline as unique agent.

Steroid therapy (dexamethasone daily 40 mg) and IVIG (daily 35g) were initiated then these drug were stopped. CHOP-like regimen ( Etoposide 75 mg/m2, twice a week for two weeks then once a week until the seventh week) and Rituximab (375 mg/m2, once a week for 4 weeks) were initiated and continued for two weeks. Later on the patient died because of sepsis and multi-organ failure.

Conclusions The multidisciplinary approach is very important. Physicians should be aware of HLH, because early recognition may prevent irreversible organ damage and subsequent death.4,5 In adults, HLH-associated mortality remains high, especially in patients with underlying malignancies.

Collapsing glomerulopathy is the most commonly reported finding on renal biopsy. Renal prognosis appears to be poor with most patients remaining dialysis-dependent.

The increased awareness of HLH, together with a more rapid diagnostic workup and new therapeutic approaches, will improve the prognosis of HLH in adults.

Role of Maraviroc in minimizing the risk of graft rejection in HIV-infected kidney transplant recipients

BACKGROUND

Kidney transplantation in HIV-infected patients is characterized by a concerning high rate of allograft rejections. The etiological mechanisms leading to this increased immunoreactivity are still unknown. Maraviroc is a new antiretroviral agent that has been associated with immunomodulatory proprieties; therefore, its use may be a promising strategy to minimize the rate of rejections in HIV-infected kidney transplant (KT) recipients.

METHODS

We conducted a retrospective study in our cohort of HIV-KT recipients with the aim to explore the effects of maraviroc in reducing the risk of graft rejection.

RESULTS

Twenty-two HIV-infected KT recipients predominantly of Caucasian origin (86%) and with a median age of 49 (IQR, 51.9-42.2) years were evaluated. Ten HIV-infected patients were treated with maraviroc and 12 with a maraviroc-free antiretroviral regimen. After a median follow-up of 3.01 years, half of the maraviroc-treated patients (n = 5) developed seven episodes of graft rejection, most of them were T cell-mediated rejections (85.7%). Five episodes were recorded in the maraviroc-free group. The difference in the rate of graft rejections was not statistically significant (P = .23).

CONCLUSIONS

The administration of maraviroc was ineffective in preventing graft rejections in our cohort of patients.

Comparison Between Kidney Transplantation After Circulatory Death and After Brain Death: A Monocentric Retrospective Study After 1 Year of Follow-up

BACKGROUND

Donation after circulatory death (DCD) is a solid resource to widen the kidney donor pool. Italian activity has grown in the last years with encouraging results. Our center has been active in DCD kidney transplantation (KTX) since November 2017, providing 22.5% of Italian DCD donations in 2018. We present a single-center retrospective analysis after a 1-year follow-up comparing DCD and donation after brain death (DBD) KTX outcomes.

METHODS

DCD (controlled only) and DBD KTX performed in our center from November 2017 to December 2018 were considered. All DCDs underwent in situ normothermic perfusion with extracorporeal membrane oxygenation, ex situ hypothermic oxygenated perfusion, and renal biopsy prior to allocation. We considered features of donors and recipients, immunosuppressive regimen, delayed graft function (DGF), primary nonfunction (PNF), graft and patient survival (Kaplan-Meier), creatinine, and estimated glomerular filtration rate at 1 year. Mean comparison with a Student t test and with χ² test for frequencies were elaborated.

RESULTS

Twenty-eight DBD, 18 double (64.3%) and 10 single (35.7%), were performed; 7 DCD, 3 double (42.8%) and 4 single (57.2%), were performed. By comparing single and double KTX, no statistically significant difference was found. We recorded 7 DGFs (25%) in DBD and 1 (14.3%) in the DCD group (P > .99) and no PNF. No graft was lost during the first year. One-year estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration) was, respectively, 62.7 ± 25.3 and 54.71 ± 14.66 mL/min (P = .25). DBD patient survival rate was 92.8%, DCD was 100%, and Kaplan-Meier was not statistically significant (P = .72).

CONCLUSIONS

Controlled DCD is a valid resource for KTX, with similar outcomes to DBD. A multidisciplinary donor evaluation, combining clinical, perfusion, and histologic data in the allocation process, allows excellent results.

Successful treatment of BK virus associated-nephropathy in a human immunodeficiency virus-positive kidney transplant recipient

BK virus (BKV) is an opportunistic pathogen in those with impaired immunity. Viral replication is generally asymptomatic but is able to induce cytopathic alterations in renal cells. If BKV infection is left untreated, it leads to BKV-associated nephropathy (BKVAN) and graft loss. There is scarce experience in the management of BKV infection in kidney transplant recipients living with HIV. We report the successful treatment of BKVAN in an HIV-positive kidney transplant recipient who experienced BKV replication in the immediate post-transplantation period. A change in therapy from calcineurin inhibitor to sirolimus, steroid withdrawal and a short course of an immunomodulatory agent (leflunomide) controlled BKV viremia in the absence of drug side-effects or impairment of graft function.

Relapse of Atypical Hemolytic Uremic Syndrome During Pregnancy in a Patient on Eculizumab Maintenance Treatment: A Case Report

Patient: Female, 28

Final Diagnosis: Relapse of atypical hemolytic uremic syndrome during pregnancy

Symptoms: Anemia • edema • hemolysis • oliguria

Medication: —

Clinical Procedure: —

Specialty: Nephrology

Kidney Disease in HIV Infection

Antiretroviral therapy (ART) has significantly improved life expectancy of infected subjects, generating a new epidemiological setting of people aging withHuman Immunodeficiency Virus (HIV). People living with HIV (PLWH), having longer life expectancy, now face several age-related conditions as well as side effects of long-term exposure of ART. Chronic kidney disease (CKD) is a common comorbidity in this population. CKD is a relentlessly progressive disease that may evolve toward end-stage renal disease (ESRD) and significantly affect quality of life and risk of death. Herein, we review current understanding of renal involvement in PLWH, mechanisms and risk factors for CKD as well as strategies for early recognition of renal dysfunction and best care of CKD.

Antiviral activity of sirolimus in an HIV-positive kidney transplant recipient

Sirolimus (SIR) is a potent immunosuppressive agent with multiple proprieties. We report beneficial antiviral effects of SIR in an HIV-positive kidney transplant recipient who experienced low-level HIV-1 replication. The immunosuppressive agent was well tolerated by the patient, and no side effects were reported during follow-up. Despite immunosuppressive monotherapy, SIR ensured stable graft function.

Efficacy of Belimumab for active lupus nephritis in a young Hispanic woman intolerant to standard treatment: a case report

Background

Lupus nephritis (LN) is a frequent severe complication of Systemic Lupus Erythematosus (SLE), especially in patients of non-Caucasian ethnicity. Induction treatment for LN consists in the combination of steroids plus a second agent (cyclophosphamide or mycophenolate mofetil) or, as a second-line, calcineurin inhibitors or Rituximab. Induction treatment for LN can be complicated by a series of side effects, the most severe being serious infections. Belimumab is a fully humanized monoclonal antibody that targets soluble B lymphocyte stimulator (BLyS), approved for treatment of serologically active SLE in addition to standard of care.

Case presentation

A young Hispanic woman was diagnosed with SLE at the age of 15. After several immunosuppressive treatments for arthritic symptoms (high-dose steroids, mycophenolate mofetil, Rituximab, cyclophosphamide) leading to serious complications and scarce clinical improvement, she developed severe LN. Induction treatment with a combination of intravenous high-dose methylprednisolone and cyclophosphamide was started but, after few days, the patient developed cryptococcal meningitis. After institution of appropriate antifungal therapy, treatment with Tacrolimus was attempted but poorly tolerated by the patient and withdrawn. Eventually, Belimumab was initiated off-label as a last resource to treat LN. Belimumab was well tolerated by the patient and resulted in a rapid and marked improvement in clinical symptoms and reduction in proteinuria, serum complement levels and anti-dsDNA titer; of note, the patient developed no infectious complications.

Conclusions

We report the case of a severe LN in a young Hispanic woman who did not respond to conventional and second-line induction therapies, due both to intolerance and to the development of serious infectious complications. Eventually, Belimumab was successfully added to steroids and was well tolerated by the patient, resulting in a marked improvement in clinical and biochemical parameters. We suggest that Belimumab should be considered as a potentially efficacious treatment in patients with LN who cannot tolerate conventional therapies.

[Challenges and results of the PIRP project (Prevenzione della Insufficienza Renale Progressiva) of the Emilia-Romagna Region]

The PIRP project was conceived in 2004; with the aim to face the increased prevalence of chronic kidney disease (CKD) associated with the aging and increased survival of the population. The first phase of the project consisted of training primary care physicians to identify people at risk of CKD and to implement intervention strategies that proved to be effective in preventing CKD it or delaying its progression once it is established. In the second phase of the project, dedicated ambulatories were opened in the nephrology units of Emilia-Romagna hospitals to provide an in-depth assessment and personalized care to CKD patients, following them up until renal failure or death or referring them back to general practitioners, according to the study protocol. A web-based registry was implemented to collect demographic and clinical data on PIRP patients. As of 30 June 2018, the registry included 26.211 CKD patients, with a median follow-up of 24.5 months. Over the 14 years of the PIRP the mean age of incident patients increased from 71.0 years to 74.2 years and the mean eGFR increased from 30.56 to 36.52 mL/min/1.73 m ², proving that the project was successful in recruiting older patients with a better renal function. At 5 years, the percentage of patients still active in the project was =45%.The implementation of the project has seen a reduction in the number of patients arriving every year to the dialysis treatment in E-R (about 100 units less from 2006 to 2016). The PIRP cohort is the largest in Italy and in Europe, which makes it ideal for research based on international comparisons and as a model for national registries.

Immunophenotypic profile and clinical outcome of monoclonal B-cell lymphocytosis in kidney transplantation

Monoclonal B-cell lymphocytosis (MBL) is a lymphoproliferative disorder characterized by clonal expansion of a B-cell population in peripheral blood of otherwise healthy subjects. MBL is divided into CLL (chronic lymphocytic leukemia)-like, atypical CLL-like and non-CLL MBL. The aim of this study was to evaluate immunophenotypic characteristics and clinical outcomes of MBL in kidney transplant (KT) recipients. We retrospectively evaluated 593 kidney transplant (KT) recipients in follow-up at our center. Among them, 157 patients underwent peripheral blood flow cytometry for different clinical indications. A 6-color panel flow cytometry was used to diagnose MBL. This condition was detected in 5 of 157 KT recipients. Immunophenotypic characterization of MBL showed four cases of non-CLL MBL and one case of CLL-like MBL. At presentation, median age was 65 years (range 61-73). After a median follow-up of 3.1 years (95%CI; 1.1-5) from diagnosis, patients did not progress either to CLL or to lymphoma. The disorder did not increase the risk of malignancy, severe infections, graft loss and mortality among our KT recipients. Surprisingly, all cases were also affected by concomitant monoclonal gammopathy of undetermined significance, which did not progress to multiple myeloma during follow-up. In conclusion, our data suggest that MBL is an age-related disorder, with non-CLL MBL being the most common subtype among KT recipients.

Clinical outcome of kidney transplantation in HIV-infected recipients: a retrospective study

Kidney transplantation is a safe and effective option for HIV-positive (HIV⁺) patients. We conducted a retrospective study on HIV⁺ kidney transplant recipients who underwent transplantation from March 2008 to September 2016. Inclusion criteria for transplantation were CD4+ T-cell count ≥200 per mm³ and undetectable HIV load. The current study reports the outcome of 19 HIV⁺ recipients, mostly of Caucasian origin (79%) with a median age of 50 years (interquartile range [IQR], 42-52), who were followed up for a median period of 2.4 years (IQR, 1.2-4.6) after transplantation. Compared with HIV-negative (HIV^-) controls, HIV⁺ recipients had similar one- and three-year graft and patient survival, but significantly lower five-year patient survival (P = 0.03). The differences in graft outcome became less evident with the analysis of death-censored graft survival rates. Cumulative incidence of allograft rejection at one year was 32.9%. Rates of infections were not particularly elevated and HIV replication remained well controlled in all but one patient. A high prevalence of metabolic and endocrine complications (68%) was reported after transplantation. Further studies are needed to evaluate long-term outcomes of HIV⁺ recipients who underwent kidney transplantation.

Rhodococcus equi Pneumonia in Kidney Transplant Recipient Affected by Acute Intermittent Porphyria: A Case Report

Rhodococcus equi is a gram-positive coccobacillus responsible for severe infections in patients with weakened immune systems. R equi generally causes pnumonia that may evolve into fatal systemic infection if left untreated. Here, we present a case of a 67-year-old woman affected by acute intermittent porphyria (AIP) who developed R equi pneumonia 7 months after kidney transplantation. Although clinical features at presentation were nonspecific, lung computed tomography showed right perihilar consolidation with a mass-like appearance causing bronchial obstruction. Appropriate antibiotic including intravenous meropenem and oral azithromycin that was then switched to oral levofloxacin and oral azithromycin along with reduction of immunosuppressive therapy resolved pneumonia without provoking an acute attack of porphyria. AIP limited the choice of antibiotics for the treatment of R equi infection because some potentially porphyrinogenic antibacterial agents were avoided. Based on this experience, azithromycin and meropenem can be safely administered for the treatment of R Equi infection in patients with AIP.

Knowledge and Attitudes Toward Organ Donation in Health Care Undergraduate Students in Italy

INTRODUCTION

The number of organ donors in Italy is increasing, but with still disappointing living donation activity and relatively frequent objection by potential deceased donors' relatives to organ recovery. Few studies have assessed health care students' knowledge and attitude on donation.

METHODS

We administered a questionnaire to medical (MS) and nursing students (NS) at University of Modena and Reggio Emilia, Italy, and 749 students (406 MS and 343 NS) completed the questionnaire.

RESULTS

Although 95% of students were in favor of donation, only 21.9% of NS and 24.9% of MS were registered as donors. One quarter of students reported family disagreement. MS appeared more confident with personnel involved in donation. Overall, 60% of students knew the term donation after brain death but only 40% were aware of the criteria used to define it. Barely 27.1% of NS and 15.3% of MS believed they had received sufficient information in lessons. Backward logistic regression demonstrated that students whose families agree with them and who knew the definition of donation after brain death were more likely to express the disposition of registering, and those who showed distrust in the declaration of brain death were half as likely to register as donors.

DISCUSSION

Students expressed a lack of knowledge, controversial attitudes on donation, and strong need for education; increased awareness may help increase donation rates. The majority of educational institutions in Italy do not directly address training on organ donation and transplantation for health care students; an integrated curriculum favoring interpersonal discussion including practical aspects is urgently required.

Comparison of Immunoassays for Tumor Markers CA 19-9, CA 15-3 and CA 125: Data from an International Quality Assessment Scheme

Data collected in the 1993 and 1994 cycles of an international external quality assessment (EQA) program and in a national multicenter collaborative study were cumulatively analyzed to evaluate the standardization of the methods currently in use for the assay of mucinous tumor markers CA 19-9, CA 15-3 and CA 125. On average the between-laboratory variability was 15.2 and 16.0 CV% for CA 15-3 and CA 125 respectively; the between-laboratory variability found for CA 19-9 was markedly worse (mean 28.3 CV%). The variability component attributable to systematic differences between different methods/kits was relatively small for CA 15-3 and CA 125 (18% and 24% of the total variability) but markedly larger for CA 19-9 (48% of the total variability). The agreement of CA 19-9 results worsened in the last few years when new nonisotopic techniques became available. The precision of the methods/kits most used in the survey ranged from 9.9 to 13.3 CV% for CA 125 and from 11.6 to 13.9 CV% for CA 15-3. For these two tumor markers the precision of the traditional IRMAs does not appear different from that of the new fully automated nonisotopic techniques. The precision of CA 19-9 methods was on average worse (from 11.7 to 19.6 CV%) although two automated systems exhibited a precision better than that of IRMAs. In conclusion, the results of this study indicate that CA 15-3 and CA 125 are satisfactorily assayed whereas CA 19-9 assay appears affected by larger differences between methods and by poorer precision of laboratories and kits.

Evaluation of Critical Differences of CEA and CA15.3 Levels in Serial Samples from Patients Operated for Breast Cancer

In the present investigation we evaluated the variability of tumor marker levels in the follow-up of patients without evidence of disease after resection of primary breast cancer. CEA and CA15.3 were measured using commercially available methods in serial blood samples collected from 170 patients. The coefficient of variation among all samples from each patient, which accounts for the total variability (analytical variability + biological variability), was widely scattered (from 4 to 99% for CEA; from 4 to 52% for CA15.3). The critical difference was calculated using the formula designed by Eraser [CD = 2.77. (CVa2 + CVb2)1/2]. It ranged from 11 to 276 for CEA and from 11 to 144 for CA15.3. From the present findings we conclude that:

1) it is possible to identify individually tailored decision criteria to evaluate tumor marker variations in the follow-up of breast cancer patients;

2) in a considerable number of cases the non-tumor-related variability is too high to allow the early identification of minor tumor marker variations that are of clinical relevance.

Mathematical Model Application to the Kinetic Study of Tumor Markers

In order to overcome the inefficient cutoff criterion in the management of neoplastic patients after therapy, in follow-up, in recurrence and in monitoring treatment, we have analysed some mathematical models to evaluate serial determinations of tumor markers, with the aim to ascertain the radicality of surgery or the presence of recurrences.

Since a tracer study of the biological system of tumor markers is impossible, some information, such as rate factor and half-life, is obtained by determination of the marker after radical treatment.

In steady state with two or more samples in time it is possible with adequate statistical models to establish a significant increase in the marker.

In recurrence, if it is true that the secretion rate of the marker by a tumor is proportional to tumor mass, then increasing concentrations of the tumor marker would be a phenotypic expression of tumor growth.

Therefore some mathematical models are proposed to evaluate the kinetics of tumor growth.

Serum Biochemical Markers of Bone Turnover in Healthy Infants and Children

Serum osteocalcin (OC), bone alkaline phosphatase (BAP), carboxyterminal propeptide of type I procollagen (PICP), carboxyterminal telopeptide of type I collagen (ICTP), parathyroid hormone (PTH) and 1,25 dihydroxyvitamin D [1,25(OH)2D] were measured in 241 normal infants and children (134 males and 107 females aged 1.9 months-14 years, 1.8 months-12 years, respectively). Regarding the analysis of data for children above 2 yrs, we chose data with the following normalization: data/body surface x standard body surface, to eliminate biological variations not exclusively related to chronological age. The increase in serum OC occurred at the expected age of growth spurts in both sexes: in the first year of life OC values (mean ± SD) were 82.6 ±34.3 and 60.2 ± 32.9 OC ng/ml in males and females, respectively; during puberty, peak values occurred at the age of 10–12 yrs in girls (76.6 ± 25.8) and at the age of 12–14 yrs in boys (113 ± 48.3). Furthermore, significant positive correlations with age were found for males from 2 to 14 yrs (p < 0.00001) and for females from 2 to 12 yrs (p < 0.001). Elevated levels of BAP occurred in the first year, 70.4 ± 28.2 and 71.8 ± 28.5, and in the second year, 69.4 ± 26.7 and 67.4 ± 33.8 ng/ml, for males and females, respectively. For children older than 2 yrs, a positive correlation with age (p < 0.01) was found for females only, with a peak value of 67.2 ± 13.9 at the age of 10–12 yrs. For ages 2–14 yrs the reference values (mean ± 2SD) were 15.5 – 90.3 and 17.2 – 95.2 ng/ml for males and females, respectively. The highest PICP levels (1354 ± 680 ng/ml in males and 1041 ± 766 in females) were observed in infants less than 1 year of age, decreasing by about 60% at the age of 2. There was no significant change in serum PICP for children older than 2 yrs with values covering a range (mean ± 2SD) of 52 – 544 and 18 – 546 ng/ml in males and females, respectively. Similarly, the highest ICTP values were seen in infants younger than 1 year (29.7 ± 11.7 and 29.5 ± 20.1 ng/ml in males and females, respectively). In the ages from 2 to 14 yrs there did not seem to be any systematic age-correlated changes, with values covering a range (mean ± 2SD) of 6.06 – 24.5 in boys and 6.84 – 22.9 ng/ml in girls. Serum PTH concentrations (mean ± SD) in infancy were 27.2 ± 19.3 pg/ml for males and 25.8 ± 10.8 for females. Normal ranges (mean ± 2SD) in the older group were 5.77 – 53.1 and 6.71 – 57.3 pg/ml for males and females, respectively. Serum 1,25(OH)2D presented values of 47.3 ± 28.1 and 38.7 ± 18.2 pg/ml under 2 yrs for males and females, respectively. The ranges (mean ± 2SD) in children above 2 yrs were 9.5 – 101 pg/ml in boys and 10.9 – 88.4 in girls. The results of this study contribute to the establishment of reference values in normal children for these biochemical assays; these reference values are needed when the above biological markers will be applied in the monitoring of metabolic bone diseases.

Serum NSE, CEA, CT, CA 15-3 Levels in Human Lung Cancer

The significance of neuron specific enolase (NSE) was investigated in comparison with other tumor markers (CEA, CT, CA 15-3) used in the diagnosis and treatment monitoring of lung cancer.

As previously described, the calcitonin assay proved to have very low sensitivity for small cell lung cancer (SCLC). The serum NSE assay was, however, shown to be a useful diagnostic aid for discrimination between histologically different lung cancers, and therefore this assay may be a valuable tool for treatment monitoring in SCLC patients.

CA 15-3, also an unspecific marker, showed similar sensitivity to the NSE assay in SCLC patients, the sensitivity being higher than CEA in non small cell lung cancer (NSCLC)

Gastric Mucormycosis in a Liver and Kidney Transplant Recipient: Case Report and Concise Review of Literature

Mucormycosis is an uncommonly encountered fungal infection in solid organ transplantation. The infection is severe and often results in a fatal outcome. The most common presentations are rhino-sino-orbital and pulmonary disease. We describe a rare case of gastric mucormycosis in a patient with a combined liver-kidney transplant affected by glycogen storage disease type Ia. A 42-year-old female patient presented with gastric pain and melena 26 days after transplantation. Evaluation with upper endoscopy showed two bleeding gastric ulcers. Histological examination of gastric specimens revealed fungal hyphae with evidence of Mucormycetes at subsequent molecular analysis. Immunosuppressive therapy was reduced and antifungal therapy consisting of liposomal amphotericin B and posaconazole was promptly introduced. Gastrointestinal side effects of posaconazole and acute T-cell rejection of renal graft complicated management of the case. A prolonged course of daily injections of amphotericin B together with a slight increase of immunosuppression favored successful treatment of mucormycosis as well as of graft rejection. At 2-year follow-up, the woman was found to have maintained normal renal and liver function. We conclude that judicious personalization of antimicrobial and antirejection therapy should be considered to resolve every life-threatening case of mucormycosis in solid organ transplantation.

Dialysate Flow Distribution in Hollow Fiber Hemodialyzers with Different Dialysate Pathway Configurations

The efficiency of a hemodialyzer is largely dependent on its ability to facilitate diffusion, since this is the main mechanism by which small solutes are removed. The diffusion process can be impaired if there is a mismatch between blood and dialysate flow distribution in the dialyzer. The objective of the paper was to study the impact of different dialysate compartment designs on dialysate flow distribution and urea clearances.

Eighteen hollow fiber 1.3 m2 hemodialyzers were studied, 6 each of 3 designs: Type A- standard fiber bundle (PAN 65DX Asahi Medical, Tokyo, Japan); Type B - spacing filaments external to the fibers (PAN 65SF Asahi Medical, Tokyo, Japan); Type C - fibers waved to give Moiré structure (FB130 Nissho-Nipro, Osaka, Japan). In vitro studies: 3 dialyzers of each type were studied following dye injection into the dialysate compartment. Dynamic sequential imaging of longitudinal sections of the dialyzer were undertaken, using a new generation helical CT scanner (X-Press/HS1 Toshiba Corporation, Tokyo, Japan). In vivo studies: 3 dialyzers of each type were studied, in randomized sequence, in 3 different patients under standardized dialysis conditions. Blood- and dialysate-side urea clearances were measured at 30 and 150 minutes of treatment.

Macroscopic and densitometrical analysis revealed that flow distribution was most homogeneous in the dialyzer with Moiré structure (Type C) and least homogeneous in the standard dialyzer (Type A). Space yarns (Type B) gave an intermediate dialysate flow distribution. Significantly increased urea clearances (p<0.001) were seen with Types B and C, compared to the standard dialyzer. Type C (Moiré) had the highest clearances although these were not significantly greater than Type B (space yarns).

In conclusion, more homogeneous dialysate flow distribution and improved small solute clearances can be achieved by use of spacing yarns or waved (Moiré structure) patterns of fiber packing in the dialyzer. These effects are achieved probably as a result of reduced dialysate channeling resulting in a lower degree of mismatch between blood and dialysate flows. The new radiological technique using the helical CT scanner allows detailed flow distribution analysis and has the potential for testing future modifications to dialyzer design.

Intraoperative Fall in Plasma Levels of Intact Parathyroid Hormone in Patients Undergoing Parathyroid Adenomectomy

Intraoperative measurement of intact parathyroid hormone (PTH) can be used to evaluate the success of parathyroid surgery in primary hyperparathyroidism associated with parathyroid adenoma. To evaluate this approach we used a modified immunoradiometric assay (IRMA) to study the kinetic patterns of circulating PTH disappearance in 13 patients undergoing adenomectomy for single adenoma. The rapid and the standard assay for PTH measurement in plasma were used and compared. The two methods showed a highly significant correlation (r=0.995; p<0.0001).

We reported a decrease in PTH to 18.2±2.30 (mean±SEM) from baseline values at 15 minutes after successful parathyroid adenomectomy in the 13 patients. The biphasic pattern of serum PTH clearance was calculated in 8 of the studied patients with a fast phase showing a half-life (T1/2) of 3.99 (SEM 0.464) minutes and a slow phase with a T1/2 of 91.0 (SEM 33.6) minutes. Half the amount of the basal values was reached between 4 and 9 minutes.

Our study concludes that the modified IRMA for intraoperative measurement is feasible, reliable and sufficiently precise for low hormone values. Since it may yield information on the half-life of PTH in the circulation, it may play a role in the surgical guidance for total exeresis of hyperfunctioning tissue

In Vitro and in Vivo Evaluation of a New Polysulfone Membrane for Hemodialysis. Reference Methodology and Clinical Results: (Part 1: In Vitro Study)

Different high flux membranes have been recently developed. The present study is aimed at describing the technical features and the clinical performances of a new high flux polysulfone membrane (T-sulfone, Toray Japan). The study has been carried out on two different dialyzers (surface area = 1.3 and 1.8 m2). The filters have been tested in vitro under definite experimental conditions. The hydraulic flow resistance, the pressure drop in the blood compartment and the hydraulic permeability have been determined in a wide range of in vitro experimental conditions. The in vitro sieving coefficients for various solutes have also been determined utilizing human blood. Hydraulic permeability was found in the range of 28.4 ml/h/mmHg/m2 and sieving coefficients were between 0.96 and 1.0 for all low molecular weight solutes. The sieving coefficient for inulin was 0.95. The pressure drop in the filter at 300 ml/min of blood flow was 95 mmHg for the 1.3 m2 and 57 mmHg for the 1.8 m2. The filters are then designed to operate in the presence of high blood flows without excessive resistance in the blood compartment. The blood compartment analyzed by means of a special radiological sequence obtained with a helical scanner after dye injection confirmed the homogeneous distribution of the blood flow in several cross sections of the bundle. Adequate distribution of dialysate was confirmed with a similar method applied to the dialysate compartment. The new imaging techniques utilized were greatly helpful to determine adequacy of filter design and flows distribution.

Predicting Prostate Biopsy Outcome by Findings at Digital Rectal Examination, Transrectal Ultrasonography, PSA, PSA Density and Free-To-Total PSA Ratio in a Population-Based Screening Setting

The study offers a retrospective analysis of the positive predictive value (PPV) of several variables, i.e. digital rectal examination (DRE), transrectal ultrasonography (TRUS), PSA value, PSA density (PSAD), and free/total PSA ratio (F/T), for the histologic outcome of 179 prostate biopsies performed within a population-based screening trial. The ratio of spared benign biopsies to missed cancers (SBB/MC) if biopsy results had been decided on the basis of single variables was also evaluated. PPV was 82.9% for DRE, 56.3% for TRUS, 26.6% for PSA (cutoff ≥4 ng/mL), 47.4% for PSA (cutoff ≥10 ng/mL), 42.0% for PSAD (cutoff 0.15), 59.2% for PSAD (cutoff 0.20), 34.9% for F/T (cutoff 0.20) and 40.0% for F/T (cutoff 0.15). SBB/MC was 121/23 for DRE, 96/12 for TRUS, 11/10 for PSA (cutoff ≥4 ng/mL), 107/34 for PSA (cutoff ≥10 ng/mL), 87/23 for PSAD (cutoff 0.15), 109/26 for PSAD (cutoff 0.20), 45/8 for F/T (cutoff 0.20) and 70/14 for F/T (cutoff 0.15). Multivariate analysis of the association with biopsy outcome showed the highest odds ratio for TRUS (13.24, 95% CI=4.4–30.7), and considerably lower values for DRE (4.17, 95% CI=2.0–8–9), PSAD (cutoff 0.20: 3.24, 95% CI=–1.8–5.7) and F/T (cutoff <0.15: 3.16, 95% CI =1.7–1.8). None of the possible variable combinations was clinically useful: the highest PPV (83.3%) was obtained with a combination of suspicious DRE/TRUS, PSAD >0.20 and F/T <0.15, which nevertheless missed 20 of 52 cancers.

[Screening Test of Fabry Disease in Patients with Renal Replacement Therapy in the City of Modena]

BACKGROUND

Fabry disease is a rare genetic lysosomal storage disease, inherited in an X-linked manner, characterized by lysosomal deposition of globotriaosylceramide due to deficient activity of the enzyme α-galactosidase A. Because the prevalence of this genetic disorder is unknown in the Emilia Romagna region, we conducted a screening study to assess the prevalence of Fabry disease in the city of Modena, Italy.

MATERIAL AND METHODS

A screening study has been conducted in patients on renal replacement therapy at University Hospital of Modena. Screening tests have been performed using dried blood spot method. Alpha-galactosidase A activity and Lyso-Gb3 levels were evaluated in peripheral blood of all men. In women test based on genetic analysis; Lyso-Gb3 was measured only in patients with mutation of gene GLA.

RESULTS

Screening tests have been performed on 388 subjects: 181 maintenance hemodialysis patients, 166 kidney transplant recipients and 41 peritoneal dialysis patients. About 40% of the patients did not had etiological diagnosis of renal disease. Lyso-Gb3 was more specific test than α- galactosidase A (100% vs. 82.5%) to diagnose Fabry disease. We found two different mutations: c.13 A >G p.(Asn5Asp), a variant likely benign and c.937 G >T p.(Asp313Tyr) a variant of uncertain significance. Both the patients carrying these genetic mutations had no symptoms or medical history compatible with Fabry disease.

CONCLUSION

Identification of variant of uncertain significance such as c.937G >Tp.(Asp313Tyr) showed the limits of genetic analysis to diagnose an inherit disease. Further studies are need to assess the diagnostic value of Lyso-Gb3 for screening for Fabry disease.

On line filtration of dialysate: structural and functional features of an asymmetric polysulfone hollow fiber ultrafilter (Diaclean®)

The endotoxin transfer across dialysis membranes has been investigated using specific in vitro circuits. Backdiffusion and backfiltration have been analyzed and most dialysis membranes have shown to be permeable to LAL positive substances. Synthetic membranes however display the better capacity of retention of these products despite their higher porosity and permeability. For such reason synthetic polysulfone ultrafilters are used as pyrogen filters to obtain ultrapure dialysate. We have investigated the characteristics of a polysulfone ultrafilter named Diaclean and manufactured by Amicon Ireland. The capacity of endotoxin retention has been investigated both in filtration and backfiltration modes on new and used ultrafilters. The capacity of endotoxin adsorption was investigated as well. Used ultrafilters appeared to maintain the retention capacity and the adsorption capacity up to 4 months of use. Only slight differences were noted from the baseline values (p = n.s.). The best adsorption capacity is always displayed by the outer layer of the membrane suggesting its best utilization in back filtration mode with tangential flow. No morphological changes were observed in the used membrane analyzed by scanning electron microscopy.

Leaching and Corrosion of Polyvinyl Chloride (PVC) Tubes in a Dialysis Water Distribution System

PVC tubes, from the dialysis water distribution system of a 14 and a 7 year old plant, were analysed by scanner electron microscopy (SEM) and X-ray microanalysis (EDAX). Results showed that the leaching of material occurs depending on time of use. The phenomenon does not modify the chemical composition of the material. Results suggest that PVC alterations, induced by time, could support bacterial proliferation thus reducing the quality of dialysate.

Analysis of PSA Velocity in 1666 Healthy Subjects Undergoing Total PSA Determination at Two Consecutive Screening Rounds

The study purpose was to assess PSA velocity (PSAV) in healthy subjects in order to establish a reliable cutoff for the differential diagnosis of prostate cancer in a screening setting. We studied a series of 1666 healthy men aged 55 to 74 years undergoing two total PSA determinations at a four-year interval within a population-based randomized screening trial at the Centro per lo Studio e la Prevenzione Oncologica of Florence. First and second screening round PSA assays (PSA1 and PSA2) were carried out with the same method and by the same laboratory. PSAV (PSA1–PSA2/year) was determined in non-cancer subjects in the overall series or in specific age and PSA subgroups, and in subjects with cancer detected at the second screening round. Average PSAV in 1648 non-cancer subjects was 0.07 ng/mL/year (range −2.18+5.99, 95% CI 0.05–0.09); at least one third of subjects showed a decrease in PSA (negative PSAV), mostly of limited magnitude and in the low PSA range. Average PSAV in the 18 cancer patients was 1.16 ng/mL/year (range 0.10–5.6, 95% CI 0.56–1.77), which is significantly higher (p<0.01) than in non-cancer subjects. None of the cancer patients showed a PSA decrease over time. Whatever cutoff was taken for PSAV, its power to discriminate cancer was limited: in particular the previously used PSAV cutoff of 0.75 ng/mL/year would have included only 42 of the 1648 non-cancer subjects (specificity 97.5%) but excluded eight of the 18 cancer patients (sensitivity 55.5%). At best, with the adopted screening protocol PSAV (cutoff 0.10 ng/mL/year) could have spared 27.9% of non-cancer subjects with PSA ≥2.5 ng/mL further diagnostic assessment and 22.7% of non-cancer subjects with PSA ≥4 ng/mL random sextant biopsy, while missing no cancers. This study provides a reliable estimate of PSAV based on a large unbiased population sample. PSAV is widely variable over time, particularly at low PSA values. PSAV might be of value as an indicator for diagnostic assessment and random sextant biopsy in a screening setting.

Evaluation of Dialysis Access Care by Means of Process Quality Indicators

Improvement of dialysis access management depends on technical skill but also on effective choice, construction, monitoring and revision of the access. Surgical procedure is only one step of a complex course, beginning with the referral of patients to nephrologists.

Using two process quality indicators, we describe the evolution of access management at our centre, where access surgery and access-related activities are performed by nephrologist. The first process indicator is based on the prevalence of temporary access at first dialysis (TA1st) in end stage renal disease ESRD patients, the second one measures the prevalence of permanent central venous catheters (%CVC) in dialysis population.

TA1st increased to 27.1% in 1999, more than twofold compared to the previous year. There was also an increase in %CVC from 20.6 to 26.3%. Native access remained the most utilised, well above 70% of dialysis patients.

Our process monitoring suggests a rapid worsening of late referral, as indicated by the increasing use of temporary catheters at the beginning of chronic dialysis. Increasing surgical activity and diagnostic procedures were only partly effective in containing the rise in CVC.

Venous sparing, early referral, Continuous Quality Improvement and a multiprofessional access-team coordinated by a nephrologist could be the key-elements in facing the never-ending-story of dialysis vascular access.

The prevalence of autosomal dominant polycystic kidney disease (ADPKD): A meta-analysis of European literature and prevalence evaluation in the Italian province of Modena suggest that ADPKD is a rare and underdiagnosed condition

Background and objectives

ADPKD is erroneously perceived as a not rare condition, which is mainly due to the repeated citation of a mistaken interpretation of old epidemiological data, as reported in the Dalgaard's work (1957). Even if ADPKD is not a common condition, the correct prevalence of ADPKD in the general population is uncertain, with a wide range of estimations reported by different authors. In this work, we have performed a meta-analysis of available epidemiological data in the European literature. Furthermore we collected the diagnosis and clinical data of ADPKD in a province in the north of Italy (Modena). We describe the point and predicted prevalence of ADPKD, as well as the main clinical characteristics of ADPKD in this region.

Methods

We looked at the epidemiological data according to specific parameters and criteria in the Pubmed, CINAHL, Scopus and Web of Science databases. Data were summarized using linear regression analysis. We collected patients’ diagnoses in the Province of Modena according to accepted clinical criteria and/or molecular analysis. Predicted prevalence has been calculated through a logistic regression prediction applied to the at-risk population.

Results

The average prevalence of ADPKD, as obtained from 8 epidemiological studies of sufficient quality, is 2.7: 10,000 (CI95 = 0.73–4.67). The point prevalence of ADPKD in the province of Modena is 3.63: 10,000 (CI95 = 3.010–3.758). On the basis of the collected pedigrees and identification of the at-risk subjects, the predicted prevalence in the Province of Modena is 4.76: 10,000 (CI 95% = 4.109–4.918).

Conclusion

As identified in our study, point prevalence is comparable with the majority of the studies of literature, while predicted prevalence (4.76: 10,000) generally appears higher than in the previous estimates of the literature, with a few exceptions. Thus, this could suggest that undiagnosed ADPKD subjects, as predicted by our approach, could be relevant and will most likely require more clinical attention. Nevertheless, our estimation, in addition to the averaged ones derived from literature, not exceeding the limit of 5:10,000 inhabitants, are compatible with the definition of rare disease adopted by the European Medicines Agency and Food and Drug Administration.

Kidney Transplantation in HIV-Infected Recipients: Therapeutic Strategy and Outcomes in Monocentric Experience

BACKGROUND

In Human immunodeficiency virus (HIV)-positive patients undergoing kidney transplantation, outcomes and immunosuppression (IS) protocol are not yet established due to infectious and neoplastic risks as well as to pharmacokinetic interactions with antiretroviral therapy (TARV).

METHODS

We report a retrospective, 1-center study on 18 HIV+ patients undergoing, between October 2007 and September 2015, kidney transplantation (13 cases) or combined kidney-liver transplant (5 cases). Inclusion criteria for transplant were based on the Italian National Transplant Center protocol. IS regimen was based on quick tapering of steroids and the use of mTOR inhibitors (mTORi) with low dose of calcineurin inhibitors (CNI). In the early post-transplant period, TARV was based on enfuvirtide, raltegravir, plus 1 or more nucleoside analogues.

RESULTS

In a mean follow-up of 3.1 years, patient survival rate at 1 and 3 years was, respectively, 86.6% and 84.6%, whereas graft survival was 81.2% and 78.6%. Cumulative rejection rate was 20.0% and 26.6% (1- and 3-year results). Median eGFR (MDRD) was 58.8 mL/min and 51.9 mL/min at 1 and 3 years. We had 9 cases of clinically relevant infections (2 Pneumocystis jirovecii pneumonia, 1 pulmonary aspergillosis, 2 severe sepsis, and 4 HCV reactivation) as well as 1 case (5.5%) of HIV reactivation.

CONCLUSIONS

IS therapy based on mTORi and low CNI dose ensures good graft survival, low rate of acute rejection, limited drug toxicity, and control of HIV disease. TARV has no significant interaction with IS therapy.