Role of nutritional therapy on dietary habits and glycemic control in insulin-treated kidney transplant patients with diabetes.

AIMS: To evaluate the effect of nutritional therapy on glycemic compensation and key cardio-renal risk markers in patients with diabetes and kidney transplant, on insulin treatment by Multiple Daily Injection (MDI) or Continuous Subcutaneous Insulin Infusion (CSII). METHODS: 34 patients with diabetes on insulin treatment and kidney transplant recipients were enrolled;12 participated in the structured nutritional program (intervention group), 22 patients (control group) did not receive nutritional protocol. Both groups were then divided into subgroups according to the method of insulin administration (MDI and CSII). RESULTS: Statistically significant reduction in fasting blood glucose values, glycosylated hemoglobin (HbA1c) and glycosuria were observed in both groups at the end of the study. The intervention group, significantly reduced total cholesterolemia and the glycemic index, together with reduced dietary intake of lipids, cholesterol, soluble carbohydrates and increased consumption of carbohydrates and fiber. These improvements were even more pronounced in patients treated with CSII. CONCLUSIONS: A proper nutritional approach optimize glycometabolic outcomes and contribute significantly to the reduction of the major cardiovascular risk factors in renal transplant patients.

High progesterone levels during the luteal phase related to the use of an aromatase inhibitor in breast cancer patients.

OBJECTIVE: To evaluate the hormonal profile in three breast cancer patients who underwent controlled ovarian stimulation in the presence of the aromatase inhibitor letrozole. PATIENTS AND METHODS: In IVF University referral center, a case series of three breast cancer patients who underwent controlled ovarian stimulation (COS) with recombinant FSH and letrozole were investigated. Ovulation was induced with hCG (case No. 1) or with GnRH agonist (case No. 2-3). The primary outcome of our study was the detection of progesterone levels in the luteal phase. RESULTS: Very high progesterone values (mean 186.6 ± 43.6 ng/mL) during the luteal phase were recorded in all three cases. CONCLUSIONS: High progesterone levels can be related to the use of letrozole independently of the most commonly used trigger regimen. Although progesterone has long been considered a protective factor against breast cancer, several studies have demonstrated that progesterone could expand a transformation-sensitive stem cell population in the mammary glands. The estrogen negative feedback effect on the hypothalamus-pituitary axis and the disruption of steroid biosynthesis and could represent an intriguing reason behind this phenomenon. Our results highlight the need to evaluate further the increase in progesterone levels in the luteal phase in women with breast cancer undergoing COS with letrozole.

Choroidal neovascularisation as an unusual ophthalmic manifestation of cat-scratch disease in an 8-year-old girl.

To report the first case of choroidal neovascularisation (CNV) that appeared during the primary Bartonella henselae infection in an 8-year-old girl. An 8-year-old girl was referred to our clinic complaining of a central scotoma in the right eye. Fundus examination revealed a bilateral disc oedema and in the right eye neuroretinitis with macular star and CNV, which was confirmed by fluorescein angiography. The optical coherence tomography revealed the presence of macular serous retinal detachment. Laboratory analysis showed rising IgM and IgG titres for B. henselae. Cat-scratch disease was diagnosed, and an 8-week treatment with azithromycin was initiated. In addition, an intravitreal injection of ranibizumab was performed in the right eye to treat the CNV. A month later, we decided to administer a systemic antibiotic again for an additional 5 months, due to the persistence of papillitis. Cat-scratch disease should be considered among the different causes of inflammatory CNV secondary to infectious uveitis. Our case was the first described in the literature in which a CNV appeared during the primary infection and not as a later complication. The combination of systemic antibiotic treatment with intravitreal anti-VEGF therapy was a successful choice because it allowed us to obtain the complete resolution of neuroretinitis, associated with the scarring of the choroidal neovascular membrane, with a final visual acuity of 20/20 in both eyes.

[Nutritional graph for Argentina's bariatric population]. / Gráfica alimentaria para la población bariátrica Argentina.

INTRODUCTION: A food graph is a guide that helps individuals controlling and improving their feeding quality; it provides recommendations on what should a particular population eat with a correct selection of the nutrients to be consumed. OBJECTIVE: The aim of this publication was to create a food education tool for bariatric surgery patients in the long run of the post-surgical period. METHODS: Graduates in nutrition and physicians specialized in nutrition were invited to participate in workshops at a meeting that took place in 2011. The scientific bases were the First Argentinean Consensus on Nutrition in Bariatric Surgery and the Feeding Guidelines for Normal Argentinean Population. In this way, these guidelines are adapted to the Argentinean population submitted to bariatric surgery, together with the experience of the healthcare professionals. RESULT: This yielded an oval-shaped food graph, an adaptation of the Feeding Guidelines for Normal Argentinean Population, 12 messages or recommendations focused on individuals with bariatric surgery, a recommended menu with a mean energetic value of 1,273 calories per day, 145 g of carbohydrates, 76 g of proteins and 43.2 g of fat; 45.5% of the calories coming from carbohydrates, 24% from proteins, and 30.5% from fat, with 1,160 mg of calcium.

Introducción: Una gráfica alimentaria es una guía que ayuda a los individuos a controlar y a mejorar la calidad de su alimentación; ofrece pautas sobre lo que debe comer una determinada población en términos de alimentos dando un marco para la correcta selección de los nutrientes a consumir. Objetivo: El objetivo de la presente publicación fue crear una herramienta de educación alimentaria destinada a pacientes de cirugía bariátrica para el postoperatorio en el largo plazo. Métodos: Se convocó a participar en mesas de trabajo a licenciados en nutrición y médicos especialistas en nutrición en un congreso realizado en el 2011. Se tomó como base científica el Primer Consenso Argentino de Nutrición en Cirugía Bariátrica y las "Guías alimentarias para la Población Argentina normal". De esta forma se adapta la misma a la población argentina con cirugía bariátrica sumada a la experiencia de los profesionales. Resultado: Como resultado se obtuvo un gráfica alimentaria en forma de óvalo, adaptación de la gráfica de las "Guías alimentarias para la población argentina", 12 mensajes o recomendaciones dirigidas a individuos con CB, una sugerencia de menú que responde a un valor calórico promedio de 1.273 calorías diarias, 145 g de carbohidratos, 76 g de proteínas y 43,2 g de grasas; 45,5% de calorías proveniente de los carbohidratos, 24% de calorías proveniente de las proteínas y 30,5 % de calorías proveniente de las grasas, 1.160 mg de calcio.

Gráfica alimentaria para la población bariátrica argentina / Nutritional graph for Argentina’s bariatric population

Introducción: Una gráfica alimentaria es una guía que ayuda a los individuos a controlar y a mejorar la calidad de su alimentación; ofrece pautas sobre lo que debe comer una determinada población en términos de alimentos dando un marco para la correcta selección de los nutrientes a consumir. Objetivo: El objetivo de la presente publicación fue crear una herramienta de educación alimentaria destinada a pacientes de cirugía bariátrica para el postoperatorio en el largo plazo. Métodos: Se convocó a participar en mesas de trabajo a licenciados en nutrición y médicos especialistas en nutrición en un congreso realizado en el 2011. Se tomó como base científica el Primer Consenso Argentino de Nutrición en Cirugía Bariátrica y las «Guías alimentarias para la Población Argentina normal». De esta forma se adapta la misma a la población argentina con cirugía bariátrica sumada a la experiencia de los profesionales. Resultado: Como resultado se obtuvo un gráfica alimentaria en forma de óvalo, adaptación de la gráfica de las «Guías alimentarias para la población argentina», 12 mensajes o recomendaciones dirigidas a individuos con CB, una sugerencia de menú que responde a un valor calórico promedio de 1.273 calorías diarias, 145 g de carbohidratos, 76 g de proteínas y 43,2 g de grasas; 45,5% de calorías proveniente de los carbohidratos, 24% de calorías proveniente de las proteínas y 30,5 % de calorías proveniente de las grasas, 1.160 mg de calcio (AU)

Introduction: A food graph is a guide that helps individuals controlling and improving their feeding quality; it provides recommendations on what should a particular population eat with a correct selection of the nutrients to be consumed. Objective: The aim of this publication was to create a food education tool for bariatric surgery patients in the long run of the post-surgical period. Methods: Graduates in nutrition and physicians specialized in nutrition were invited to participate in workshops at a meeting that took place in 2011. The scientific bases were the First Argentinean Consensus on Nutrition in Bariatric Surgery and the Feeding Guidelines for Normal Argentinean Population. In this way, these guidelines are adapted to the Argentinean population submitted to bariatric surgery, together with the experience of the healthcare professionals. Result: This yielded an oval-shaped food graph, an adaptation of the Feeding Guidelines for Normal Argentinean Population, 12 messages or recommendations focused on individuals with bariatric surgery, a recommended menu with a mean energetic value of 1,273 calories per day, 145 g of carbohydrates, 76 g of proteins and 43.2 g of fat; 45.5% of the calories coming from carbohydrates, 24% from proteins, and 30.5% from fat, with 1,160 mg of calcium (AU)

PINK1 protects against cell death induced by mitochondrial depolarization, by phosphorylating Bcl-xL and impairing its pro-apoptotic cleavage.

Mutations in the PINK1 gene are a frequent cause of autosomal recessive Parkinson's disease (PD). PINK1 encodes a mitochondrial kinase with neuroprotective activity, implicated in maintaining mitochondrial homeostasis and function. In concurrence with Parkin, PINK1 regulates mitochondrial trafficking and degradation of damaged mitochondria through mitophagy. Moreover, PINK1 can activate autophagy by interacting with the pro-autophagic protein Beclin-1. Here, we report that, upon mitochondrial depolarization, PINK1 interacts with and phosphorylates Bcl-xL, an anti-apoptotic protein also known to inhibit autophagy through its binding to Beclin-1. PINK1-Bcl-xL interaction does not interfere either with Beclin-1 release from Bcl-xL or the mitophagy pathway; rather it protects against cell death by hindering the pro-apoptotic cleavage of Bcl-xL. Our data provide a functional link between PINK1, Bcl-xL and apoptosis, suggesting a novel mechanism through which PINK1 regulates cell survival. This pathway could be relevant for the pathogenesis of PD as well as other diseases including cancer.

Gemcitabine in advanced angiosarcoma: a retrospective case series analysis from the Italian Rare Cancer Network.

BACKGROUND: Angiosarcoma is a highly aggressive soft tissue sarcoma. Responses to anthracyclines plus/minus ifosfamide, and taxanes alone or in combination with gemcitabine are well documented. Very few data are available on gemcitabine as a single agent. PATIENTS AND METHODS: We retrospectively reviewed all cases of advanced progressive angiosarcoma treated with gemcitabine as a single agent (1000 mg/m(2) i.v. every week for 3 weeks every 4 weeks), at Istituto Nazionale Tumori and within the Italian Rare Cancers Network from January 2008 to November 2010. RESULTS: Twenty-five patients [mean age: 52 years; radiation therapy (RT)-related: 8] received gemcitabine. Best tumor response by RECIST was as follows: complete response = 2, partial response = 14, stable disease = 2, progressive disease = 7 cases, for an overall response rate (PR + CR) of 68%. Six of eight post-RT angiosarcomas responded to treatment. Median overall survival (OS) was 17 months. Median progression-free survival (PFS) was 7 months (range 1-40 months). One patient with a locally advanced thyroid angiosarcoma became resectable after 5 months of gemcitabine, with <10% residual viable tumor cells seen on surgical specimen. Overall, gemcitabine was well tolerated. CONCLUSIONS: Gemcitabine is active in both RT- and non-RT-related angiosarcoma, with dimensional and possibly long-lasting responses. A formal phase II study on gemcitabine as a single agent is warranted.

Postexplant residual cavity hemostasis with a TachoSil patch.

Intracapsular nephrectomy as the standard explant technique for a unfunctional graft is associated with intra- and postoperative complications due mainly to hemorrhage, fluid collections, effusions from damaged tissues and the residual cavity. We have reported herein a positive experience with the use of a collagen medical sponge patch into the surgical site for hemostasis. Use of this device produced a reduction in postoperative bleeding and collections with shortened time of drainage, reduced infection risk, and earlier discharge.

Multiorgan retrieval and horseshoe kidney: case report.

Horseshoe kidney, a congenital anatomic condition with fusion of the kidney poles, causes the organ to be placed around the aorta usually below the origin of the mesenteric artery. This congenital disorder affects about 1 in 400 people. Retrieval for multiorgan transplantation dissects and canulates major abdominal vessels, aorta and vena cava, below the renal vessels to infuse refrigerated preservation solution. The presence of a horseshoe kidney could be a hazard for the retrieval team when cannulating when following standard techniques. We have described herein a surgical maneuver exposing the anterior surface of the aorta for canulation. We transected the horseshoe kidney in the midline with the use of a linear cutter stapler GIA 60 mm (Ethicon), after previously ligating both kidney pedicles. This technique was safely performed without the need for cannulation through the iliac vessels.

Saccular aneurysm of graft renal artery: case report.

Repair of anatomic anomalies in a donor kidney's vascular structures requires prompt recognition of the aberrant condition and an appropriate repair technique that does not compromise transplant success. Our report describes a case of a saccular aneurysm of the donor kidney, renal artery, which was identified during harvesting and repaired on the back-table using a prosthetic patch derived from the excised lesion to cover the breach. The long-term results were good.

Bench surgery in right kidney transplantation.

The problems deriving from the anatomic differences between the two harvested kidneys make the bench surgery necessary to solve some technical difficulties in transplantation. This condition is particularly real in the case of right kidney transplantation, especially in presence of arterial anomalies. In this study, we focused our attention on venous reconstruction in cases of short renal right veins. In 3 years, we performed 55 consecutive cadaveric renal transplants in patients with an end-stage chronic renal insufficiency. The right kidney was used in 30 patients, eight of whom had two or more arteries attached to a single aortic patch, and 22 had a single artery. In these right transplanted kidneys, the elongation of renal vein was performed end-to-side to the external iliac vein, reconstructing a "T-patch" (angular reconstruction) in 28 patients and a "linear" one in two cases. The vascular anastomoses had no thrombotic problems. We have followed the progress of the patients for more than 2 years; no one has lost the graft due to chronic rejection or other complications. In conclusion, elongation of the right renal vein with a T-patch constitutes a feasible, physiological procedure without vascular complications or apparent reverberations for graft blood flow.

Posttransplant renal monitoring with B-flow ultrasonography.

B-flow ultrasonography (BFU) is a new technology to detect blood circulation. It has been developed by using digitally encoded sonography, showing higher spatial and temporal resolution than Doppler imaging because of the clearer definition of the vessel lumen. Our study was performed on 55 patients, including 37 men (67.3%) and 18 women (32.7%), of overall mean age of 45.8 years (range = 16-60 who underwent kidney transplantation from deceased donors. The patients underwent an ultrasonography check postoperatively with successive daily controls to compare evaluations with both techniques: the combination of color and power Doppler versus BFU. In 25 patients (45.5%), visualization of cortical blood flow was clearer than with the standard techniques. The parameters of intrarenal circulation were easy to measure. In conclusion, BFU was effective to visualize hemodynamic flow and to detect stenotic lesions in the renal artery. Combined with the conventional B-mode technique, BFU seems to be useful in the evaluation of renal anasthamotic stenosis, especially among patients with vascular diseases.

Low limb and allograft rescue with iliofemoral graft for external iliac artery dissection: case report.

The technical difficulties in performing a transplantation can often be joined by an accident that demands an urgent solutions, putting the life of the patient in serious risk. In our case we were forced to perform an iliofemoral PTFE graft substitution to save the vascularization of the right lower limb. The cause was constituted by a dissection in the external iliac artery wall immediately after upstream declamping. Fortunately quick understanding of the complication made us stop the lesion downstream before it involved the femoral district. In addition the renal artery was already not declamped and the organ not perfused. Successively we anastomosed the renal artery to the PTFE graft with an end-to side anastomosis. Our first target was obviously to preserve the low limb vascularization but, with this solution we managed also to save the allograft. Actually renal function is conserved and with an optimal state of the vascular graft.

The finding of vascular and urinary anomalies in the harvested kidney for transplantation.

INTRODUCTION: In kidney transplantation, anatomical vascular and excretory anomalies may represent causes of failure. Today's surgical techniques have made the most of the organs with anatomic anomalies and iatrogenic injury successfully used for transplantation. MATERIALS AND METHODS: From January 2000 to June 2006, we harvested 230 kidneys, of including 88 kidneys (20%) with vascular, urinary, or vascular-urinary anomalies; 64 kidneys were implanted and 15 were sent to other transplantation centers. Only 9 kidneys were not appropriate for transplantation. RESULTS: All patients who received kidneys with the above-mentioned anomalies were carefully examined after the transplantation and short-term and long-term complications were evaluated with respect to controls without anomalies. DISCUSSION: Renal anatomic anomalies are frequently observed during kidney transplantation and may produce postsurgical complications. However, the presence of these anomalies does not necessarily imply the impossibility of using the kidney for a transplant, especially because of improved surgical techniques. Our experience in transplantation procedures showed that even if kidneys present the above-mentioned anomalies they can still be considered appropriate for transplantation when we perform a correct harvesting/back-table transplant surgery. So vascular and urinary anomalies have to be considered always an incentive to research new surgical solutions and to perform a careful surgical technique.

Older kidneys donor transplantation: five years' experience without biopsy and using clinical laboratory and macroscopic anatomy evaluation.

INTRODUCTION: The exponential increase in organ demand is not associated with a similar increase of available kidneys. This emergency led to expanded criteria to consider a kidney transplantable. The aim of this retrospective study was to explain our use of older donor kidneys without biopsy. MATERIALS AND METHODS: Between 2000 and 2005, 58 older kidneys were harvested: 27 were transplanted in our center; 13 were discarded; and 18 were transplanted in other centers. We considered 3 factors to define kidney quality: macroscopic anatomy, multiple factors linked to the donor, and clinical-laboratory data. After transplantation, we observed the patients for at least 1 year and up to 6 years. DISCUSSION: At 1 year, 24/27 (89%) patients had a functional kidney, 2 patients showed an initial renal failure and 1 patient lost the kidney. At maximum follow-up, 19 patients (70%) had functional kidneys, 4 with initial renal failure. These results compared with the kidneys harvested using Standard Donor Kidney Criteria are acceptable. Obviously we need long-term follow-up to increase, the amount of data and obtain a definitive outcome. CONCLUSION: Biopsy is the gold standard for the definition of an older kidney's quality. When a biopsy is not feasible, the study of the macroscopic anatomy the kidney's donor and of some donor's parameters represent an acceptable biopsy alternative, being able to rescue some organs that would be otherwise lost.

Difficult vascular conditions in kidney transplantation.

The new dialytic and medical therapies have improved the survival of uremic patients and their preservation of a efficacious clinical condition so as to warrant suitability for transplantation, even after a long period of dialysis. In addition, today the use of a "marginal donor" and "marginal kidney" are often used to increase the pool of available organs, so that the surgeon must face more technical difficulties than in the past; anomalies of the donor kidney, harvesting and bench surgery damages, as well as vascular pathologies in the recipient. A review of our 151 renal transplantations from January 1999 to May 2003 showed that it was often possible to overcome these technical difficulties yielding good results. This work sought to demonstrate that neither "marginal donor"/"marginal kidney" used to expand donor pool nor recipient vascular pathologies should be considered transplant contraindications. Knowledge of various technical options and the ability to put them rapidly into practice are necessary to use any organ.

Healing of surgical incision in kidney transplantation: a single transplant center's experience.

INTRODUCTION: Impaired healing of the surgical incision represents a common complication after kidney transplantation. We led a retrospective study seeking to understand the factors linked to these complications and reasons for their reduction during the last year. PATIENTS AND METHODS: From January 2000 to April 2004, 170 consecutive kidney transplantations were performed in a homogenous patient population. We evaluated the influence of following factors to determine impaired healing of the incision: antirejection drugs, overweight/obesity, age, delayed graft function (DGF), diabetes, and abdominal wall reconstruction technique. RESULTS: Among 165 patients we observed 26 (15.76%) cases of impaired healing of the surgical incision: 17 (65,38%) with first-level and nine with second-level wound complications. CONCLUSIONS: Impaired healing of the surgical incision influences the outcome of kidney transplant patients. In our study we observed that cyclosporine and tacrolimus similary affected the incision's healing. It was not possible to evaluate the role of basiliximab. A univariate analysis of the factors related to complications revealed overweight and DGF. However, all patients developing second-level complications showed more risk factors. Patients who had not had reconstruction of the muscle layers showed a greater incidence of surgical complications, whereas patients who had skin sutured with an intradermic technique did not show an increased risk.

Transplantation and young surgeons in Italy.

The relation between young surgeons and transplantation has always been a "love and hate" one. Until a few years ago this branch of surgery was seen as pioneering, with extreme and and extensive training, and was reserved to few elected members. Nowadays things are different. In this article we try to understand the true reasons that young Italian surgeons avoid transplantation surgery.

Suboptimal kidney: the experience of a single transplant unit.

Not all kidneys are suitable for transplantation. In 2001 in Italy, only 1530 of 1748 organs were transplanted. This difference (-12.5%) not only represents organs harvested from marginal donors considered not suitable, but also kidneys that, although collected from standard donors, had a vascular, parenchymal, or urologic anomaly that made them unsuitable for transplantation. In our center, we established a procedure that defined the characteristics of suboptimal kidneys and allowed us to specifically select the appropriate recipient. We considered as suboptimal all organs with complex arterial anomalies (more than 2 arteries although on a single patch or separated such as to need a double anastomosis or a bench reconstruction); organs with noticeable parenchymal damage (macroscopic sclerosis areas or sutured polar branches accidentally damaged during removal), and organs with complex anomalies of the excretory tract (complete double district). The organs were not considered as suboptimal if they had venous anomalies revised on the bench or if they had a double artery with a single patch <2.5 cm. Such organs were transplanted to recipients who were between 55 and 60 years of age with a body weight of at least 20% less than the donor, and female.

"Tube-guided" implant of bioprosthetic shunt for hemodialysis.

Implant of a bovine-derived vascular bioprosthesis as arterio-venous shunt for hemodialysis may raise some problems regarding tunnel fashioning. Therefore, we have proposed a simple "tube-guided" technique to make implant safer and to avoid complications.