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Piccoli GB, Attini R, Parisi S, Vigotti FN, Daidola G, Deagostini MC, Ferraresi M, De Pascale A, Porpiglia F, Veltri A, Todros T. Excessive urinary tract dilatation and proteinuria in pregnancy: a common and overlooked association? BMC Nephrol 2013; 14:52. [PMID: 23446427 PMCID: PMC3600000 DOI: 10.1186/1471-2369-14-52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/07/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Proteinuria and dilatation of the urinary tract are both relatively common in pregnancy, the latter with a spectrum of symptoms, from none to severe pain and infection. Proteinuria is a rare occurrence in acute obstructive nephropathy; it has been reported in pregnancy, where it may pose a challenging differential diagnosis with pre-eclampsia.The aim of the present study is to report on the incidence of proteinuria (≥ 0.3; ≥ 0.5 g/day) in association with symptomatic-severe urinary tract dilatation in pregnancy. METHODS Case series. SETTING Nephrological-Obstetric Unit dedicated to pregnancy and kidney diseases (January 2000-April 2011). SOURCE database prospectively updated since the start of the Unit. Retrospective review of clinical charts identified as relevant on the database, by a nephrologist and an obstetrician. RESULTS From January 2000 to April 2011, 262 pregnancies were referred. Urinary tract dilatation with or without infection was the main cause of referral in 26 cases (predominantly monolateral in 19 cases): 23 singletons, 1 lost to follow-up, 1 twin and 1 triplet. Patients were referred for urinary tract infection (15 cases) and/or renal pain (10 cases); 6 patients were treated by urologic interventions ("JJ" stenting). Among them, 11 singletons and 1 triple pregnancy developed proteinuria ≥ 0.3 g/day (46.1%). Proteinuria was ≥ 0.5 g/day in 6 singletons (23.1%). Proteinuria resolved after delivery in all cases. No patient developed hypertension; in none was an alternative cause of proteinuria evident. No significant demographic difference was observed in patients with renal dilatation who developed proteinuria versus those who did not. An association with the presence of "JJ" stenting was present (5/6 cases with proteinuria ≥ 0.5 g/day), which may reflect both severer obstruction and a role for vescico-ureteral reflux, induced by the stent. CONCLUSIONS Symptomatic urinary tract dilatation may be associated with proteinuria in pregnancy. This association should be kept in mind in the differential diagnosis with other causes of proteinuria in pregnancy, including pre-eclampsia.
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Piccoli GB, Daidola G, Attini R, Parisi S, Fassio F, Naretto C, Deagostini MC, Castelluccia N, Ferraresi M, Roccatello D, Todros T. Kidney biopsy in pregnancy: evidence for counselling? A systematic narrative review. BJOG 2013; 120:412-27. [PMID: 23320849 DOI: 10.1111/1471-0528.12111] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Kidney diseases, which have a prevalence of 3% in women of childbearing age, are increasingly encountered in pregnancy. Glomerulonephritis may develop or flare up in pregnancy, and a differential diagnosis with pre-eclampsia may be impossible on clinical grounds. Use of kidney biopsy is controversial, but a systematic review has not been carried out to date. OBJECTIVES To review the literature on kidney biopsy in pregnancy, with a focus on indications, risks and timing. SEARCH STRATEGY Medline, Embase, CHINAL and the Cochrane Library were searched in September 2012, with 'pregnancy' and 'kidney biopsy' used as MESH and free terms, for the period 1980-2012. Results were filtered for 'human' if this option was available. SELECTION CRITERIA Biopsies during pregnancy and within 2 months after delivery. Case reports (fewer than five cases) and kidney grafts were excluded. Paper selection was performed in duplicate. DATA COLLECTION AND ANALYSIS Data were extracted in duplicate. The high heterogeneity in study design necessitated that the review be narrative, except for data on adverse events, which were analysed with regard to the timing of kidney biopsy. MAIN RESULTS Of 949 references, 39 were selected, providing data on 243 biopsies in pregnancy and 1236 after delivery (timing was unclear in 106 women). The main aims of the studies were to define morphology in pre-eclampsia (23 studies), to carry out a risk-benefit analysis of kidney biopsy (11 studies), and to investigate pregnancy-related acute kidney injury (five studies). Four cases of major bleeding complications occurred at 23-26 weeks of gestation. Relevant complications were observed in 7% of women during pregnancy and 1% after delivery (P = 0.001). Kidney biopsy performed for the diagnosis of glomerulonephritis or pre-eclampsia led to therapeutic changes in 66% of cases. AUTHORS' CONCLUSIONS The evidence on kidney biopsy in pregnancy is heterogeneous, but a significantly higher risk of complications (relative to postpartum biopsy) was found, with a possible peak at around 25 gestational weeks.
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Piccoli GB, Vigotti FN, Balduini CL, Pecci A. The Case | Proteinuria and low platelet count. Kidney Int 2012; 81:927-8. [DOI: 10.1038/ki.2012.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Piccoli GB, Attini R, Vigotti FN, Naretto C, Fassio F, Randone O, Restagno G, Todros T, Roccatello D. NEMO syndrome (incontinentia pigmenti) and systemic lupus erythematosus: a new disease association. Lupus 2012; 21:675-81. [PMID: 22235006 DOI: 10.1177/0961203311433140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Congenital diseases are increasingly being recognised in adults because of clinical mimicry, variable clinical picture or rarity of the disease; pregnancy is a valuable diagnostic occasion. The present case is the first report of an association report between NEMO syndrome (an acronym of the mutated, non-functioning gene, NF-kB essential modulator), a rare X-linked disease, characterised by developmental anomalies, immunodepression and skin lesions, and systemic lupus erythematosus (SLE). A 35-year-old patient affected by SLE sought clinical advice in the 8th week of gestation. The diagnosis of SLE dated back to the age of 24, when multisystemic manifestations (pleuropericarditis, weight loss, alopecia, skin involvement, joint pain, kidney involvement) were observed. She had been treated with steroids since 1999; immunosuppressive drugs had been added for short periods. Developmental anomalies were present, including oligodontia, retinal problems, anomalies of the corpus callosum and pes planovalgus. Family history included multiple miscarriages, dental malformations and oligodontia and skin blistering in the first months of life. On these bases, incontinentia pigmenti (IP; or NEMO syndrome) was diagnosed and confirmed by genetic testing. The NEMO gene is implicated in immune deficiencies as well as in autoimmune diseases. This report may suggest a role for NF-kB essential modulator in the pathogenesis of SLE, in the context of the complex immunologic deficiencies increasingly associated with autoimmune diseases.
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Piccoli GB. The never-ending search for the perfect dialysis. Should we move from the best treatment to the best system? Nephrol Dial Transplant 2011; 26:1128-31. [PMID: 21460360 DOI: 10.1093/ndt/gfr123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Piccoli GB, Karakas SL. Paula Modersohn-Becker, the challenges of pregnancy and the weight of tradition. Philos Ethics Humanit Med 2011; 6:11. [PMID: 21645346 PMCID: PMC3123279 DOI: 10.1186/1747-5341-6-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 06/06/2011] [Indexed: 05/30/2023] Open
Abstract
Paula Modersohn-Becker, widely considered to have been one of the most important independent Expressionist painters of the early twentieth century, was thirty-one years old when she gave birth to her first child. Following the then-common practice of putting women to bed rest for two-four weeks after delivery, she died of massive pulmonary embolism when she was first allowed to stand, eighteen days after giving birth. Paula had foreseen her death at a young age and was apprehensive about her pregnancy, yet she painted herself as pregnant in her best known self-portrait, thus underlining the importance of the pregnancy in her life. In the light of knowledge available at the time, the authors present a brief discussion of the life and death of Paula Modersohn-Becker as a reflection on the potential dangers of blindly following conventional wisdom in the medical profession.
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Piccoli GB, Attini R, Vasario E, Gaglioti P, Piccoli E, Consiglio V, Deagostini C, Oberto M, Todros T. Vegetarian supplemented low-protein diets. A safe option for pregnant CKD patients: report of 12 pregnancies in 11 patients. Nephrol Dial Transplant 2010; 26:196-205. [PMID: 20571094 DOI: 10.1093/ndt/gfq333] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Pregnancy in CKD is an increasing challenge, considering also the paucity of therapeutic tools available in pregnant women. While theoretically interesting, the experience with low protein diets in pregnancy is limited. Aim of this feasibility study is to review our experience with supplemented vegetarian low protein diets in pregnancy, as a "rescue treatment" for severe CKD and/or proteinuria. METHODS Data were gathered prospectively. Diet schema: proteins: 0.6-0.7 g/Kg/day, amino and chetoacid supplementation, 1-3 free meals/week. Compliance, side effects, biochemical data recorded at each visit (at least twice monthly). RESULTS Between January 2000 and February 2010, out of 168 pregnancies referred, 12 were managed by the diet (11 patients; median age 33, range 20-38). One pregnancy was terminated (patient's choice); the other 10 patients delivered 11 healthy babies. At referral, 2 patients were in stage 4 CKD, 4 in stage 3, 4 had nephrotic proteinuria (3.6-6.3 g/day). One patient doubled serum creatinine; none needed renal replacement therapy within 6 months from delivery. No patient complained of side effects, nor developed hyperkalemia or hypercalcaemia. Two babies from mothers in CKD stage 4 were small for gestational age; 9/11 were delivered by caesarean section (median gestational age 33 weeks: range 28-37; birth weight 935-2620 g) within a policy of delivery in the presence of foetal growth impairment and/or worsening of proteinuria, GFR, hypertension or foetal conditions. All babies are well, 1 month, 7.5 years from delivery. CONCLUSION Our report suggests considering vegetarian diets as an additional tool in the management of pregnant CKD patients.
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Piccoli GB. Patient-based continuum of care in nephrology: why read Thomas Addis' "Glomerular Nephritis" in 2010? J Nephrol 2010; 23:164-167. [PMID: 20213608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The name of Thomas Addis (1881-1949) is linked to several aspects of nephrological practice: from the "Addis count" of urinary elements, to the history of diet in chronic kidney diseases. He was accustomed to working with limited funds, and developed his theories with relatively simple means, combined with the careful, long-term observation of single cases. His political ideas were progressive; his outlook on life was optimistic. This is deeply reflected in his Glomerular Nephritis: Diagnosis and Treatment, a book worth reading in the era of chronic kidney disease (CKD), as it contains sharp analyses of the organizational aspects, and accurate comments on the role of the physician - all subjects of interest for the present times and challenges. One of Addis' ingenious ideas was to follow his patients throughout their lifelong disease, thus anticipating the theories of continuum of care and of therapeutic alliance between patients and physicians. He used to tailor his prescriptions and frequency of controls to each patient and phase of the disease, thus anticipating the tailored therapies and the patient empowerment presently considered as fundamental in chronic diseases. Furthermore, he suggested that physicians should work outside the hospital in small coordinated teams, in which volunteers, dietitians and laboratory technicians would play a crucial role. Patient-centered care and the importance of nonmedical team members are clear from the first lines of his book. As far as we know, he was the first physician to stress the role of volunteers in CKD, anticipating by decades nonprofit organizations such as the National Kidney Foundation.
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Piccoli GB, Mezza E, Bermond F, Mowatt G, Faggiano F. Home versus hospital or satellite unit haemodialysis for end-stage renal failure. Hippokratia 2008. [DOI: 10.1002/14651858.cd004758.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Piccoli GB, Mezza E, Grassi G, Faggiano F, Calderini M, Sampo' D, Gentile L. Dialysis and transplantation for end-stage renal disease in adults. Hippokratia 2008. [DOI: 10.1002/14651858.cd003896.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Segoloni GP, Giraudi R, Messina M, Rossetti M, Biancone L, Leonardi G, Piccoli GB, Magnano A, Gai M. No recurrence of Kaposi's sarcoma in a case of renal retransplantation under a calcineurin inhibitor free immunosuppressive regimen: first report. Transpl Int 2007; 20:395-6. [PMID: 17326783 DOI: 10.1111/j.1432-2277.2006.00435.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Piccoli GB, Bermont F, Magnano A, Soragna G, Terzolo M. Prolactinoma in a diabetic dialysis patient with erectile dysfunction: a difficult differential diagnosis. Rev Diabet Stud 2007; 3:200-4. [PMID: 17487344 PMCID: PMC1828284 DOI: 10.1900/rds.2006.3.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Dialysis patients often suffer from erectile dysfunction. The prevalence of this symptom in the context of dialysis is as high as 90%. Diabetes, diffuse vascular disease and pharmacological therapy are attendant causes of this condition, severely impairing the quality of life. Due to the high frequency of erectile dysfunction in uremic patients, minimalist diagnostic approaches are often used. Nevertheless, a careful differential diagnosis is also warranted in well dialyzed patients to identify causes and corrigible patterns. The case reported here exemplifies this critical issue. A 44 year old obese diabetic patient complained about the recent onset of erectile dysfunction. On examination, the penile echo-Doppler was normal, and suggested a cause other than dia-betic vascular disease. The high dialysis efficiency (daily hemodialysis, flexible schedules, EKRc from 15 to 25 ml/min) warranted the same diagnostic work-up as would adopted for non-uremic patients. Whilst the rising prolactine level (76.1 microg/l and 129 ng/ml) was still in the range commonly found in dialysis patients, a nuclear magnetic resonance examination was carried out and led to the identification of prolactinoma. Therapy with cabergoline was found effective and sexual potency was restored. Normalization of hormonal patterns followed within 2 months. This is the first case so far reported in a daily dialysis patient. It underlines the importance of a non-minimalist approach to the problem of sexual disorders in renal replacement therapy (RRT) patients, at least when dialysis efficiency is high and onset is rapid. It also suggests considering prolactinoma as an emerging diagnosis in the general population, which can be detected by the use of sensitive imaging techniques in the differential diagnosis of this condition.
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Borrione P, Parisi A, Salvo RA, Spaccamiglio A, Pautasso M, Baraban D, Piccoli GB, Pigozzi F, Angeli A. A peculiar pattern of expression of the transferrin receptor (CD71) by reticulocytes in patients given recombinant human erythropoietin (rHuEPO): a novel marker for abuse in sport? J BIOL REG HOMEOS AG 2007; 21:79-88. [PMID: 18261259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
To overcome the limitation of the currently adopted direct method to detect recombinant Human Erythropoietin (rHuEpo) abuse in sport, indirect analysis of blood parameters are increasingly used as part of the anti-doping strategies. The aim of the present work is to identify whether immunophenotype modifications on erythroid cells may be indicative of previous rHuEPO administration. The study was conducted on dialyzed patients under treatment with rHuEPO (DPT). Dialyzed patients without rHuEPO therapy (DP) and volunteer donors (H) were used as controls. The analysis of erythroid cells immunophenotype, performed using a multiparametric flow cytometry technique, showed a peculiar pattern of CD71 expression following rHuEPO treatment. In particular CD71 showed an increased expression in mature and intermediate reticulocytes and a surprisingly decreased expression in immature reticulocytes. In conclusion, the analysis of reticulocyte maturation stages with TO/CD71 double staining may be considered as a valid alternative indirect method for the detection of rHuEPO abuse.
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Piccoli GB, Soragna G, Putaggio S, Consiglio V, Mezza E, Bonetto A, Geuna S. Drug use and kidney donation: what are high-risk behaviors today? Transplant Proc 2006; 38:1221-3. [PMID: 16797268 DOI: 10.1016/j.transproceed.2006.02.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND "Social risk behaviors" are usually considered as contraindications for organ donation. The organ shortage, however, necessitates expansion of the donor pool. Reconsideration of the policy toward substance abusers may be important. Opinions of the overall population may be of use to define this cultural-sensitive issue. METHODS A semistructured questionnaire on organ donation, including opinions on drug use (cannabis and cocaine), was administered to various groups of the general public and caregivers: high school students (liceo classico: 59 students, median age 18 years; istituto tecnico: 108, age 17); first- and fourth-year medical school (77, age 19; 46, age 22); continuing medical education (44, age 32); third-year nursing school (31, age 23); "senior citizen university" (51, age 63). RESULTS Cannabis use was mainly accepted for kidney donation (48.6% yes, 26.6% no, 29.8% uncertain/blank), but cocaine use was not (22.1% yes, 44.2% no, 33.7% uncertain/blank). In the univariate analysis, opinions differed according to age, sex, and belonging to the health care teams upon multivariate analysis being a member of the health care team was the strongest predictor of responses (P<.01). CONCLUSION It is difficult to define social risk behaviors. Since opinions are important for organ donation, further studies and discussion are needed to periodically analyze our policies.
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Piccoli GB, Picciotto G, Rossetti M, Burdese M, Consiglio V, Magnano A, Soragna G, Sargiotto G, Maas J, Guarena C, Veglio V, Messina M. Imaging data suggesting acute pyelonephritis in the kidney graft: report of five cases with atypical clinical presentation. Int J Antimicrob Agents 2006; 28 Suppl 1:S64-71. [PMID: 16854571 DOI: 10.1016/j.ijantimicag.2006.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute pyelonephritis is a common complication of kidney transplantation, occurring in up to 1% of grafts. Diagnosis is mainly clinical and atypical presentations have seldom been reported. The diagnostic role of imaging techniques has not been defined. Five cases of acute graft pyelonephritis are reported (three kidney, two pancreas-kidney grafts). The patients (median age 48 years) comprised three females and two males. Median post-transplant follow-up was 3 months, with three patients having predisposing factors for diabetes and one for an enteric bladder. None of the patients presented the 'classic' diagnostic tetrad (i.e. fever, positive urine cultures, low urinary tract symptoms and serum creatinine increase); although, at diagnosis, two of five patients presented with fever, one had increased creatinine levels and one had positive urine cultures. Of note, three patients had leucocyte casts at urinary sediment analysis, thus raising clinical suspicion. Renal ultrasounds were negative in all patients. Renal (99m)Tc-MAG3 (mercaptoacetyltriglycine) scintigraphy, which was used for the definition of kidney function impairment (one patient) or because of the presence of urinary casts (three patients), or after the biopsy diagnosis to locate the parenchymal lesions (one patient), was positive in all patients. The presence and pyelonephritic origin of the parenchymal lesions was confirmed by nuclear magnetic resonance or computed tomography scans. Acute graft pyelonephritis may develop in the absence of a full-blown clinical picture. Smouldering symptoms may occur in the presence of large perfusion deficits. (99m)Tc-MAG3 scintigraphy could be an important diagnostic tool in such cases.
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Piccoli GB, Consiglio V, Colla L, Mesiano P, Magnano A, Burdese M, Marcuccio C, Mezza E, Veglio V, Piccoli G. Antibiotic treatment for acute 'uncomplicated' or 'primary' pyelonephritis: a systematic, 'semantic revision'. Int J Antimicrob Agents 2006; 28 Suppl 1:S49-63. [PMID: 16854569 DOI: 10.1016/j.ijantimicag.2006.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The definition of acute pyelonephritis is controversial. There are two contrasting approaches: (1) acute pyelonephritis is a severe infectious disease involving the kidney parenchyma, and specific imaging techniques are required for diagnosis; (2) acute pyelonephritis is a urinary tract infection, and diagnosis and therapy follow simplified clinical and laboratory pathways. In this study, recent randomized controlled trials (RCTs) were systematically reviewed and the diagnostic and therapeutic approaches to acute 'uncomplicated' pyelonephritis were analysed. Medline, Embase, Cochrane Central Register of Controlled Trials (CCTR) and Chinal were searched employing Mesh, Emtree and free terms on 'pyelonephritis'. Limits included human, period (1995-2004), and trials-reviews (where available). In total, 904 references and 175 full-text were retrieved; 29 were pertinent RCTs. Seven RCTs were added from reference lists (indexed on urinary tract infections). Imaging examinations were performed in 11 of 14 studies on children (diagnostic requisite in two) and in two studies on adults; scarring was not analysed in adults. Clinical definitions varied widely (fever >37.8 to >39 degrees C, culture titres 10(4) >10(5)). Studies on adults were limited to short-term end-points (microbiological sterilization, clinical improvement). Duration of therapy was 4-20 days. The trend was towards shorter periods of therapy, mainly on an outpatient basis; intravenous therapy, if performed, was usually limited to the first 1-3 days. For acute uncomplicated pyelonephritis, the tendency is towards 2 weeks of mainly oral antibiotic therapy. However, the recent literature on adults does not discriminate among different upper urinary tract infections nor does it provide data on renal scarring. While cost constraints point towards short-term therapies, further studies are needed to assess the prevalence and long-term effect of kidney scars.
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Piccoli GB, Soragna G, Putaggio S, Consiglio V, Magnano A, Mezza E, Bonetto A, Geuna S. Is male homosexuality still a cultural taboo for kidney donation? Transplant Proc 2006; 38:1224-6. [PMID: 16797269 DOI: 10.1016/j.transproceed.2006.02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Among the so-called social risk behaviors, male homosexuality is probably one of the most interesting and difficult taboos. Because of changing attitudes of the general population toward irregular sexual behaviors, often considered as markers of unhealthy life styles, there is a need to reconsider at least the most important one-homosexuality. METHODS A semistructured questionnaire included opinions on homosexuality with respect to kidney donation: Would you consider a male homosexual as a kidney donor? If you were on dialysis, would you accept a kidney from a homosexual donor? This instrument was administered to various groups of the general public and caregivers: high school students (Liceo Classico: 59 students, median age 18 years; Istituto Tecnico: n=108, median age 17); first and fourth year of medical school (n=77, age 19; 46, age 22); continuing medical education (n=44, age 32); third year of nursing school (n=31, age 23); "senior citizen university" (n=51, age 63). RESULTS Male homosexuality was well accepted for kidney donation (71.6% yes, 9.6% no, 18.8% uncertain/blank). However, the opinions were different among the groups with male students of a technical institute showing discrimination against male homosexuals. In the univariate analysis, opinions differed according to age, gender, and belonging to the health care team. In the multivariate analysis, the latter was the strongest predictor (P<.01). The specific threats for the health are not well known, even among the caregiver population. CONCLUSION It is difficult to define the role of homosexuality among the so-called social risk behaviors. Negative attitudes existed in some subsets of the population.
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Wagenlehner FME, Piccoli GB, Naber KG. Uraemia, psychosis, young patient: an uncommon link. Urinary tract and miliary tuberculosis. Nephrol Dial Transplant 2006; 21:1113-6. [PMID: 16464882 DOI: 10.1093/ndt/gfl009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Piccoli GB, Colla L, Burdese M, Marcuccio C, Mezza E, Maass J, Picciotto G, Sargiotto A, Besso L, Magnano A, Veglio V, Piccoli G. Development of kidney scars after acute uncomplicated pyelonephritis: relationship with clinical, laboratory and imaging data at diagnosis. World J Urol 2006; 24:66-73. [PMID: 16429303 DOI: 10.1007/s00345-005-0044-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Accepted: 11/07/2005] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Acute pyelonephritis is a potential cause of kidney scars. AIM To evaluate the relationship between clinical, laboratory and imaging data and the development of kidney scars in acute pyelonephritis. METHODS All consecutive patients hospitalized for acute uncomplicated pyelonephritis in our nephrology unit from June 1996 to June 2004 were considered: 58 females, median age 25.6 years (16-52). Diagnosis of pyelonephritis required parenchymal lesions shown by CT or NMR scan. RESULTS The lesions were bilateral in 17.2% (10/58) patients, unilateral, but multifocal in 81.0% (47/58); at CT or NMR, 65.5% of the lesions were classified as simple, 19% with tendency to colliquation and 15.5% abscessual. The median interval between first symptoms and diagnosis was 5 days (1-25); at referral, only 20.7% had a positive urine culture and 94.8% (55/58) had undergone previous antibiotic treatment. The therapeutic protocol required intravenous therapy for > or = 2 weeks, followed by 2-4 weeks of oral therapy. At 6-8 months, the prevalence of kidney scars was 29.3%. Their development was highly correlated with the type of lesions at diagnosis (highest risk with abscessual lesions; uni- and multivariate analysis). No other clinical or laboratory marker (age, fever, positive cultures, levels of acute phase reactants, interval between onset and diagnosis) was correlated with the outcome (scars). CONCLUSIONS The type of lesion at diagnosis of acute uncomplicated pyelonephritis is highly correlated with the development of kidney scars. Further studies are needed to test the therapeutic schedules tailored according to the imaging data.
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Segoloni GP, Messina M, Squiccimarro G, Mazzucco G, Torta E, Leonardi G, Fop F, Roggero S, Vigotti F, Piccoli GB. Preferential allocation of marginal kidney allografts to elderly recipients combined with modified immunosuppression gives good results. Transplantation 2006; 80:953-8. [PMID: 16249744 DOI: 10.1097/01.tp.0000174134.80947.0a] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is an increasing tendency to allocate kidneys from marginal donors in older recipients. This combination optimizes the uses of an expanded donor pool but demands attention for the higher nephrotoxic sensitivity of the kidney and the increased immunosuppression vulnerability of the elderly recipients. We aimed to reduce these hazards by means of a calcineurin-free induction therapy followed by a maintenance regimen targeted to minimize/withdraw steroid. METHODS Eighty-eight single (43%) or double (57%) transplant recipients (58.4+/-5.7 years) from 88 marginal donors (67+/-8.3 years) received monoclonal anti-IL-2 receptor antibodies, mycophenolate mofetil (MMF), and steroid. When serum creatinine was less than 2.6 mg/dL, tacrolimus was started and MMF was withdrawn when the tacrolimus trough level was above 15 ng/ml. Steroid was tapered to 5 mg at day 45 and then progressively reduced. RESULTS Overall patient and graft survival at the first and fourth year were respectively 100 and 96%, and 98 and 79%. Acute rejection rate was 13.6% (12/88), creatinine clearance remained stable (48.2 ml/min at the sixth month, 50.9 ml/min at 48th month). At the first, second, third, and fourth years, 23, 69, 80, and 100% of recipients were off steroids. For those on steroids, mean dose was respectively 2.6 mg/day from month 12. No recipient re-assumed steroids CONCLUSIONS In the "old-for-old" allocation, the calcineurin-inhibitor avoidance at induction and the steroid withdrawal/minimization during the tacrolimus-based maintenance regimen allow a low acute rejection rate, a stable renal function, and favorable recipient and graft outcomes.
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Piccoli GB, Sargiotto A, Burdese M, Colla L, Bilucaglia D, Magnano A, Consiglio V, Piccoli G, Picciotto G. Cholesterol emboli syndrome in type 2 diabetes: the disease history of a case evaluated with renal scintigraphy. Rev Diabet Stud 2005; 2:92-6. [PMID: 17491684 PMCID: PMC1783551 DOI: 10.1900/rds.2005.2.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cholesterol crystal emboli syndrome (CCE) is an emerging disease, whose progression reflects the currently observed increase in cardiovascular diseases. Diagnostic criteria shifted from pathological to clinical criteria: creatinine increase, skin lesions, recent endovascular interventions and severe vasculopathy). Diabetes, hypertension and diffuse vascular disease are inter-linked, major risk factors. The role of imaging techniques in the diagnosis and treatment of the disease has been little investigated thus far. The AIM of this report is to describe a case exemplifying the potentials for renal scintigraphy in CCE, an emerging disease in type 2 diabetic patients. THE CASE A 75 year-old, type 2 diabetic for over 15 years, obese, hypertensive white man was referred to the Nephrology Unit after an acute coronary syndrome. Stenosis of the left renal artery was diagnosed from the angiography. Serum creatinine (baseline: 1.9 mg/dl) increased after multiple angioplasties to 3.3 mg/dl, then slowly returned towards baseline (2.2 mg/dl), but rose, on referral, to 3.9 mg/dl, with an increase in acute phase reactants and peripheral livedo reticularis, a picture highly suggestive of CCE. The first renal scintiscan showed a reduction of the parenchymal phase, and a non-homogeneous parenchymal pattern in the right dominant kidney. The patient was started on corticosteroid therapy with a prompt decrease in creatinine; four days later (creatinine 2.5 mg/dl) a second scintiscan showed an improvement of the peak time and of the radionuclide parenchymal transit, and was further confirmed two months later (creatinine 2.2 mg/dl). No modification was detected in the left kidney, presumably mechanically "protected" from the cholesterol shedding by the stenosis. CONCLUSIONS This is the first description of an imaging demonstration of the morpho-functional substratum to the rapid clinical response of corticosteroid therapy in a case of CCE and type 2 diabetes, underlining the potential of 99mTc-MAG3 dynamic scintiscan in this disease.
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Mezza E, Oggé G, Attini R, Rossetti M, Soragna G, Consiglio V, Burdese M, Vespertino E, Tattoli F, Gai M, Motta D, Segoloni GP, Todros T, Piccoli GB. Pregnancy after kidney transplantation: an evidence-based approach. Transplant Proc 2005; 36:2988-90. [PMID: 15686677 DOI: 10.1016/j.transproceed.2004.10.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite the relatively little space for transplantation in most medical schools, this issue is considered interesting by the students both for its clinical and ethical implications. The students were asked to choose a particular aspect of nephrology for a 2-hour case discussion. They chose the case of a 35-year-old female, kidney transplant recipient now 1.5 years postoperatively, who was coming to seek advice about pregnancy. The aim of the present work is to report an integration between narrative and evidence-based medicine (EBM) approaches. The search strategy was developed within a multidisciplinary working group, two of whose members were also masters in the methodology of systematic revisions. The first step in the discussion was the identification of ethical and methodological problem. In a rapidly developing field, books are unlikely to be able to give updated information. One needs to interact with electronic databases. In this context, no randomized controlled trial on pregnancy is expected. The evidence is likely to be heterogeneous. Prenatal care delivery differs around the world in part related to attitudes toward pregnancy, which depend upon religion and traditions. The second step was the definition of the search strategy. The third step, was selecting and cataloging the evidence. The titles and abstracts retrieved by the search strategy (272 items) were examined to identify full papers to be retrieved. The evidence retrieved was screened for the type of paper (reviews, primary studies, case reports, case series) and for the authors to give an indirect idea of duplicate publication bias. Teaching a complex and ever-changing subject, such as kidney transplantation, is a difficult task. The case of a young woman seeking information on the probability to undergo a successful pregnancy was particularly likely to exemplify the importance of being aware of the biases of the book-based information and on the need to interact with the internet. The search strategy developed by the working group of postgraduate trainees allowed students to have a direct experience with the complexity of the field. This preliminary study, as the basis for development of a checklist informed consent form on pregnancy in kidney transplantation, may give a first rough quantification of the work needed by a physician who wants to have a direct idea of the odds and risks of pregnancy in kidney transplant patients.
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Segoloni GP, Quaglia M, Giacosa C, Ferro M, Martina G, Piccoli GB. Renal transplantation from cadaveric donor after myocardial revascularization: still a matter of concern? Transplant Proc 2005; 36:2635-8. [PMID: 15621110 DOI: 10.1016/j.transproceed.2004.09.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Renal transplantation in patients who have undergone coronary revascularization remains a matter of concern, few experiences have been reported in literature. From January 1997 to March 2003, 23 previously revascularized patients underwent renal transplants from cadaveric donors. We analyzed patient survival and cardiac events in this group of patients (group A) versus a similar population of 38 revascularized patients who were still on dialysis (group B) on the active waiting list (awl). After a similar follow-up (29.30 +/- 21.34 months versus 32.98 +/- 31.33 months; P = .56), survival was 100% for renal transplant patients and 94.74% for dialysis patients, two of whom (5.26%) died from acute myocardial infarction and four (10.52%) were excluded from the waiting list because of cardiac problems. The event-person ratio was 0.51 for group A patients (75% of events clustered within the first 6 months) and 0.71 for group B. The need for therapy with nitrates decreased from 11/23 (47.8%) to 6/23 (26%) after transplant. The ejection fraction remained stable (53.82% +/- 10.4% vs pre-Tx value of 54.8% +/- 9.4%). Renal survival was 100% (sCr = 1.4 +/- 0.4 mg/dL). Although no statistical significance has emerged, there was a general trend in favor of transplanted patients. On the basis of this experience we believe that coronary revascularization per se should no longer be a matter of concern for renal transplantation, which could be superior to dialysis for this type of patient.
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Piccoli G, Colla L, Maass J, Stratta P, Bianchi C, Burdese M, Mesiano P, Marcuccio C, Mezza E, Mazzucco G, Piccoli GB. Acute pyelonephritis: a new approach to an old clinical entity. J Nephrol 2005; 18:474-96. [PMID: 16245258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Burdese M, Consiglio V, Mezza E, Savio D, Guarena C, Rossetti M, Messina M, Soragna G, Suriani C, Rabbia C, Segoloni GP, Piccoli GB. Diffuse vascular damage in a transplanted kidney: an indication for nuclear magnetic resonance? Transplant Proc 2005; 37:2063-5. [PMID: 15964339 DOI: 10.1016/j.transproceed.2005.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Indexed: 11/16/2022]
Abstract
Vascular lesions are an increasing challenge after renal transplantation due to the wider indications for recipients and acceptance criteria for donors. Diagnostic approach and prognostic interpretation are still matter of controversy. The case reported herein may summarize some of the issues in this regard. A 54-year-old woman, on renal replacement therapy since 1974, and a kidney graft recipient from 1975 to 1999, received a second graft in 2001. The donor age was 65 years (cold ischemia 22 hours; two mismatches). The early posttransplant follow-up was characterized by delayed graft function, hypertension, and diabetes. During the initial hypertension workup, renal graft ultrasound (US) Doppler demonstrated increased vascular resistances, stable over time (resistance index 0.74 to 0.77); renal scintiscan displayed homogeneously parenchymoa and angio-magnetic resonance imaging (MRI), an homogeneous parenchymal vascularization. Initial immunosuppression with tacrolimus and steroids was modulated by adding mycophenolate mofetil to taper tacrolimus (to reduce nephrotoxicity and hypertension). Despite this, kidney function slowly deteriorated; serum creatinine reached 3 to 3.5 mg/dL by the second year. After a severe hypertensive crisis with unchanged scintiscan and US doppler examinations, angio-MRI revealed the almost complete disappearance of parenchymal enhancement beyond the lobar arteries. A renal biopsy confirmed the severe vascular damage. The patient was switched to rapamycine and a low-dose of an angiotension converting enzyme (ACE) inhibitor. She did relatively well (serum creatinine 2.2 to 3 mg/dL) for 6 months, when rapid functional impairment forced her to restart hemodialysis. This case, almost paradigmatic of the problems occurring when the rigid vasculature of long-term dialysis patients is matched with "marginal kidneys," suggests that MRI may be a sensible good to define vascular damage in the grafted kidney.
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