Early Prediction of Cardiovascular Disease in Kidney Transplant Recipients.

Cardiovascular disease (CVD) is frequent after kidney transplantation (KT). This study investigated CVD prediction in KT by information available before KT or within 6 months after KT. The study cohort consisted of 629 patients with KT in 2005-10 and with adult age at KT. The end point was incidence up to 2015 of CVD (coronary heart disease, cerebrovascular disease, peripheral artery disease). Graft failure, non-CVD death with functioning graft, and loss to follow-up were considered competing events. CVD prediction was investigated for 34 variables by means of competing-risks regression. Follow-up range was 0.28-10.00 years (mean ± SD, 7.30 ± 3.10). First incident event was CVD in 103 patients and competing events in 146 patients. In the multivariable model for pre-KT variables only, CVD predictors were male sex (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.06-2.66), diabetic nephropathy (HR, 6.63; 95% CI, 1.81-24.35), pre-KT dialysis for ≥5 years (HR, 1.52; 95% CI, 1.02-2.27), pre-KT CVD (HR, 4.87; 95% CI, 2.84-8.35), and age at KT ≥45 years (HR, 2.98; 95% CI, 1.83-4.87). In the model for pre-KT and post-KT variables together, the sole post-KT CVD predictor was estimated glomerular filtration rate <60 mL/min at the 6-month visit (HR, 1.75; 95% CI, 1.11-2.77). Diabetic nephropathy, pre-KT dialysis, pre-KT CVD, and age at KT predicted 91.2% of incident CVD. Early available information effectively predicted CVD in KT independently from competing events.

[Atypical mycobacterial infection after kidney transplant: two clinical cases]. / Micobatteriosi atipiche nel trapianto renale: due casi clinici.

Infections are an important cause of morbidity and mortality during kidney transplant. In areas where tuberculosis is not endemic, Mycobacteria other than tuberculosis (MOOT), also known as 'atypical' Mycobacteria, are more frequently involved in mycobacterial infections than M. tuberculosis. The incidence of MOOT infection in renal transplant recipients ranges from 0.16 to 0.38 percent. This low rate of reported incidence is, however, often due to delay in diagnosis and lack of therapeutic protocols. Further difficulty is caused by the interaction of antimycobacterial drugs with the post-transplant immunosuppressive regimen, necessitating close monitoring of plasma concentrations and careful dose modification. We present two cases of Mycobacterium Chelonae infection in kidney transplant recipients which differ in both clinical presentation and pharmacological approach.

[Retroperitoneal dedifferentiated liposarcoma (DDLS) with hyperglycemic activity: case report and literature review]. / Liposarcoma dedifferenziato retroperitoneale con attivita ipergligemica: caso clinico e review della letteratura.

The authors describe a Retroperitoneal De Differentiated LipoSarcomas (DDLs), that for its clinical behavior shows peculiar characteristics and original aspects: typical is the recurrence due to local invasiveness, but absolutely original seems to be the surviving time, maybe correlated to its histological evolution (dedifferentiation from leiomyosarcoma to liposarcoma) and an interesting correlation from the tumor recurrence and the glycemic curve first and after the surgical treatments. A 66-year-old woman, presenting typically with very big abdominal masses, treated three times in almost three years, every time with aggressive surgical treatments. Histological response was leiomyo-sarcoma in the first two operations and liposarcoma in the last treatment and in every preoperative phase the patient, normally prediabetic, started to have problem of glycemia balancing, needing an insulin support until the postoperative phases when its glycemia was coming back in normal value without insulin needs, of course until a new tumor recurrence. This last aspect, not depending on pancreas involvement or hormonal activity (immune-histo-chemistry was never conforming a neuro-endocrine activity), seems probably due directly to a mass and metabolic effect of the tumor. Beginning from the description of this case and its interesting biology and reviewing most of the literature on the argument, authors hope to give our support to still debated and partially unknown aspects of these kinds of tumors.

[Renal dysfunction as a marker of cardiovascular risk]. / La disfunsione renale come marcatore di rischio cardiovascolare.

The evaluation of urinary albumin excretion (UAE) and estimated glomerular filtration rate (eGFR) is suggested for the assessment of cardiovascular risk. It is unclear whether UAE and eGFR provide complementary information. UAE, eGFR, cardiovascular risk factors, and the incidence of cardiovascular disease were analyzed in 45- to 64-year-old individuals involved in the Gubbio study. UAE in the highest decile was defined as high (microng/min: > or = 18.6 in men and > or = 15.7 in women), eGFR in the lowest decile as low (mL/min/1.73 m(2): <64.2 in men and <57.9 in women). Kidney dysfunction was more frequent when defined by both markers than when defined by one marker only (UAE or eGFR) because high UAE and low eGFR tended to cluster in different individuals. The hazard ratio (HR) for incident cardiovascular disease was 1.85 in individuals with high UAE only (95%CI 1.04-3.25), 1.84 in individuals with low eGFR only (95%CI 1.04-3.26), and 5.93 in individuals with high UAE and low eGFR (95%CI 2.58-13.61). Concomitant evaluation of UAE and eGFR should be considered to adequately assess kidney dysfunction and cardiovascular risk.

[Survival is not enough: improving quality of life]. / Sopravvivere non basta--migliorare la qualità della vita.

We need a new health care system that is based on patients' needs. The present cadre of health managers who acquired power by cutting expenditures must be removed from office. We need to educate a new cadre of health managers who are 1) convinced that safeguarding health does not use up the resources of the next generations; 2) capable of switching the system from curative to preventive medicine; and 3) able to reinforce clinical research. Such principles have been recently adopted by the French President Sarkozy in devising the national health care program.

[Early detection of chronic kidney disease: epidemiological data on renal dysfunction]. / L'identificazione precoce della nefropatia cronica: dati epidemiologici sulla disfunzione renale.

Estimated glomerular filtration rate (eGFR) and urinary albumin (U-Alb) have been suggested as indicators for the early identification of persons with kidney dysfunction. The Gubbio Study collected data on serum creatinine, UAlb, other laboratory indices, blood pressure, and medical history in a population sample of 4574 adults (2083 men and 2491 women, age range 18- 95 years). The study included analyses on six disorders which are commonly associated with kidney disease (hypertension, cardiovascular disease, anemia, high serum uric acid, high serum phosphorus/low serum calcium, and high serum potassium). Low eGFR (<60 mL/min per 1.73 m2) was found in 6.6% of men and 6.2% of women. Low eGFR prevalence varied largely with age (from <1% at 18-24 years up to > 30% at > or =75 years in both sexes, p<0.001). On the basis of these data, it was estimated that the prevalence of low eGFR in the whole Italian population could be 1.3 million among men (95%CI 1.1/1.5) and 1.5 million among women (95%CI 1.3/1.8). Data available only for age 45-64 indicate that 6.4% of men and 3.0% of women have high U-Alb (> or =20 microg/min) in the presence of non-low eGFR. Low eGFR was associated with at least two disorders potentially due to kidney disease in the majority of persons but was rarely associated with a previous diagnosis of kidney disease (<5% of cases). These data support the use of eGFR for the screening of people with or at risk of developing kidney disease. Awareness of kidney disease is very low in the Italian population.

[Urinary albumin excretion and coronary artery disease]. / Albumina urinaria e malattia coronarica nella popolazione di età 45-64 anni.

The moderate elevation in urinary albumin excretion defined as microalbuminuria is common in the population and associated with cardiovascular (CV) risk factors. Microalbuminuria prevalence is low in the absence of CV risk factors and progressively increases with the number of the individual's CV risk factors. The main correlate of microalbuminuria is blood pressure (BP). The relationship between BP and microalbuminuria is continuous and graded since the prevalence of microalbuminuria increases with the severity of hypertension. Among hypertensives receiving treatment, BP control is associated with a low prevalence of microalbuminuria. Therefore, BP appears as a determinant of microalbuminuria rather than a mere correlate. For hypercholesterolemia, smoking and diabetes, the data are less strong, but point to an independent positive association with microalbuminuria. Altogether, data indicate that microalbuminuria in the population reflects the presence of CV risk factors. Data concerning microalbuminuria and coronary heart disease (CHD) support this idea. There is a continuous and graded relationship between urinary albumin excretion and CHD prevalence. High urinary albumin excretion is a likely sign of vascular damage existing both at renal and cardiac levels and induced by one or more uncontrolled CV risk factors.

[Cancer risk in breast lesions: diagnostic and therapeutic strategy]. / Lesioni a rischio della mammella: protocollo diagnostico-terapeutico.

BACKGROUND: The classification, diagnostic recognition and surgical treatment of breast lesions at risk of neoplastic transformation represent some of the most important objectives in breast research. Attention has been focused on lesions at risk of neoplastic transformation in breast pathology, such as: atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), multiple intraductal papilloma and sclerosing adenosis. METHODS: Our experience regards activity carried out from 1996 to 2001; the diagnostic approach included routine performance of echotomographic examination, mammography screening indicated in women >40 and, in selected cases, in women <40; FNAB was carried out in all lesions containing suspicious cells. In the case of non-palpable lesions we carried out a CT-guided FNAB using the stereotaxic technique. In cases of secreting breast, galactography proved useful. As regard clinically suspect nipple secretions, cytology was useful in the diagnosis of intraductal papillomatous lesions. Surgery was indicated for: mammographically negative nodular lesions with cytological finding of suspect lesions. Continuous, spontaneous mono-orificial, serous, sero-hematic or hematic secretion of the nipple also in the presence of negative and/or inconclusive galactographic and cytological findings. From a nosological viewpoint we have distinguished 3 groups: A) 49 women (average age 47.3 years) with suspect lesions subjected to biopsy. On the basis of the cytological response we carried out: 37 quadrantectomies with extemporary examination, 4 excisional biopsies, 5 radical ductectomies and 3 microductectomies. B) 26 patients (36.7 years) subjected to mammary biopsy for non-suspect lesions; in 24 cases excisional biopsy of the lesion and in 2 cases radical ductectomy. C) Control group consisting of 141 women (average age 44.5 years) suffering from benign pathology not suspected of lesions at risk and not subjected to surgery. RESULTS: The final histological examination evidenced: Group A: 7 cases of T1aN0M0 carcinoma (14.3%); 20 lesions at risk (40.8%); 22 lesions not at risk; Group B: 25 (96.1%) lesions not considered at risk, in 1 case (3.9%) area of sclerosing adenosis with ductal proliferation and slight atypias; Group C: in 4 cases (3.1%) the onset at follow-up of lesions at risk made it necessary to remove the lesion. Histology did not confirm the presence of cancer in any case. CONCLUSIONS: The diagnostic and therapeutic protocol proposed enables us to identify and radically treat high risk patients (Group A) and follow them up closely. On the contrary, Group B evidenced a very low incidence of lesions at risk which escaped preoperative diagnosis and in confirmation of this in Group C, during follow-up, the onset of only 4 lesions at risk was identified in which histological examination however excluded the presence of cancer.