Skin cancers and other cutaneous diseases in renal transplant recipients: a single Italian center observational study.

Kidney transplant recipients frequently suffer from skin infections and malignancies, due to the effects of long-term immunosuppressive therapy. Herein, a dermatological screening was performed to evaluate the relationship between risk factors, cutaneous tumours and other skin diseases in a group of 282 kidney transplant patients. Infectious diseases (16.7%) were the most frequent dermatological disorders, whereas cutaneous inflammatory and autoimmune diseases were relatively rare, probably due to an indirect therapeutic role of immunosuppressive regimens. Thirty patients experienced cutaneous side effects from immunosuppressants, mainly when receiving corticosteroids (p = 0.0372). We identified 99 patients (35.1%) who developed cutaneous tumours after transplantation. Cumulative tumour incidence was observed during long-term immunosuppressive therapy; no relationships were identified between skin cancer risk and single class of drug or combination regimens. When we evaluated the eventual relevance of other risk factors for skin cancers, we demonstrated a statistical significance in univariate analysis for male gender, more advanced age at transplantation, long duration of immunosuppressive regimens, no sunscreen usage, outdoor job, absence of cherry angiomas and presence of actinic keratoses (AKs). Age at transplantation (p = 0.0174), presence of AKs (p = 0.0005) and duration of immunosuppression (p = 0.0011) also confirmed their significance in multivariate analysis.

'Bench' MRI before transplant on harvested kidneys: a possible tool for diagnosis of acute pyelonephritis.

We present the first case in which magnetic resonance imaging (MRI) has been utilized to rule out lesions compatible with acute pyelonephritis in kidneys from a cadaveric organ donor before transplanting them. A 40-year-old female underwent diagnosis of brain death following a septic shock. The ecotomography of the kidneys showed areas compatible with micro-abscesses raising the hypothesis of acute pyelonephritis. Our radiologist proposed to perform a bench-MRI (maintaining kidneys within the sterile preservation bags constantly on ice); this did not show lesions except little cysts not relevant by the clinical point of view. We transplanted kidneys without infective complications and results were very good.

Cholesterol crystal embolism syndrome in dialysis patients: an emerging clinical diagnosis?

BACKGROUND: Cholesterol crystal embolism syndrome (CCE) is an increasing end-stage renal disease cause. Few cases have been described on dialysis, despite the high prevalence of the predisposing factors. METHODS: The diagnostic criteria of the present study were: skin lesions, myalgia, fatigue, fever and acute inflammatory serologic signs, in the presence of severe vasculopathy. The precipitating factors were: anticoagulation, endovascular intervention and ulcerated atherosclerotic plaque. RESULTS: Between October 2003 and September 2005, CCE was diagnosed in 6 dialysis patients (of 200-210 on chronic treatment): 5 males, 1 female, median age 59.5 years (47-70) and end-stage renal disease follow-up 11.5 years (3-25). All had severe vasculopathy, 5 cardiopathy, and 4 were failed graft recipients. The treatment included: peritoneal dialysis, daily dialysis, 'conventional' hemodialysis (2 cases) and hemodiafiltration. The diagnosis was based on the clinical-laboratory picture in 1 patient. In the 5 others clues were present (dicumarol therapy, angioplasty, femoral artery thrombosis, CCE predialysis and ulcerated aortic plaque). The therapeutic approach consisted of corticosteroids (5 cases), statins (4 cases) and prostaglandin analogues (4 cases). CONCLUSION: The differential diagnosis of CCE should also be considered in dialysis patients (necrotic lesions, limb pain and vasculitis-like signs).

Efficacy of an educational programme for secondary school students on opinions on renal transplantation and organ donation: a randomized controlled trial.

CONTEXT: Organ shortage for transplantation is a crucial problem; educational interventions may increase donations and decrease opposition. OBJECTIVE: To test the efficacy of an educational programme on opinions on organ transplantation and kidney donation. DESIGN AND PARTICIPANTS: Cluster Randomized Controlled Trial: eight intervention and eight control schools were randomly selected from the 33 public schools that agreed to participate. Targets: students in the last 2 years of secondary school (17-18 years); seven schools per group completed the study. EDUCATIONAL PROGRAMME: INTERVENTION: first questionnaire (anonymous); 2 h lesson in each class; 2 h general session with patients and experts; second questionnaire. CONTROL: questionnaires. MAIN OUTCOME MEASURES: Differences between questionnaires (comparative analysis); interest; satisfaction with the programme; (cross-sectional analysis). RESULTS: 1776 first, 1467 second questionnaires were retrieved. Living kidney donation: at baseline 78.8% of students would donate a kidney to a relative/friend in need. The answers were unaffected by type of school but depended on sex (females more prone to donate, P<0.001); the answers did not change after the lessons. Cadaveric kidney donation: baseline opinions were mixed (intervention schools: 31.5% yes, 33.7% no, 34.8% uncertain), depending on type of school (classical-scientific high schools more positive than technical institutes, P<0.001), sex (males more prone to donate, P<0.001). Answers on living and cadaveric donation were correlated (P<0.001). The educational intervention increased favourable (31.5 to 42.9%) and uncertain (34.8 to 41.1%) opinions and decreased negative ones (33.7 to 16%) (P<0.001). CONCLUSIONS: Educational interventions are effective in increasing interest and improving opinions about cadaveric organ donation.

Dialysis choice in the context of an early referral policy: there is room for self care.

BACKGROUND: Predialysis care is vital for the patient and is crucial for dialysis choice: empowered, early referred patients tend to prefer out-of-hospital and self-care treatment; despite these claims, early referral remains too often a program more than a reality. Aim of the study was to evaluate the pattern and reasons for RRT choice in patients treated in a long-standing outpatient network, presently following 850 chronic patients (about 80% diabetics), working with an early referral policy and offering a wide set of dialysis options (home hemo and PD; self care and limited care hemodialysis; hospital hemodialysis). METHODS: Prospective historical study. All patients who started RRT in January 2001-December 2003 were considered. Correlations between demographical (sex, age, educational level) or clinical variables (pre-RRT follow-up, comorbidity, SGA and Karnofsky) and treatment choice have been tested by univariate (chi-square, Kruskal-Wallis) and multivariate models (logistic regression), both considering all choices and dichotomising choice into "hospital" versus "out of hospital dialysis". RESULTS: Hospital dialysis was chosen by 32.6% of patients; out of hospital in 67.4% (PD 26.5%, limited-care 18.4%, home hemodialysis 4.1%, self-care 18.4%). Hospital dialysis and PD were chosen by elderly patients (median age: 67.5 and 70 years respectively) with multiple comorbidities (75% and 92.3%); no difference for age, comorbidity, Karnofsky, SGA and educational level. 6/13 PD patients needed the help of a partner. Self-care/home hemodialysis patients were younger (median age 52), had higher educational level (p = 0.014) and lower prevalence of comorbidity (63.6% vs 94.7% in the other dialysis patients, p = 0.006). In the context of a long follow-up period (3.9 years) a statistically significant difference was found comparing hospital dialysis (3.3 years) vs out of hospital dialysis (4.9 years) (p = 0.035). In a logistic regression model, only pre-RRT follow-up was correlated with dialysis "hospital vs "out of hospital" choice (p = 0.014). CONCLUSION: Early nephrological follow-up may enhance self and home-based dialysis care.

Teenagers' point of view on living donor kidney transplantation: Cinderella or princess?

UNLABELLED: Living kidney donation is an important clinical option, encountering different fortunes in the world. AIM: To analyse the opinions of a large subset of older teenagers attending high school (7999 students, median age 18) on different aspects of living kidney transplantation. METHODS: Analysis of semistructured questionnaires submitted within an educational campaign on dialysis and transplantation in the high schools of Torino and its county (about 2,000,000 inhabitants). RESULTS: Over 90% of the students had already heard of transplantation, mainly via television (88.4% county, 84.5% city). 80% would donate a kidney to a family member (3.5% wouldn't, 16.5% uncertain); answers were correlated with sex (females more than males p<0.0001), school type (istituti tecnici versus licei p=0.007), interest (yes versus other p<0.0001). A lower percent of individuals would receive a kidney (58.4% county, 59.4% city), only 10% would ask for donation. Over 40% of students consider legally buying a kidney a patient's right, only 26.6% would discourage this choice. The answers were correlated with the reverse pattern as for non-mercenary donation with type of school (licei more than istituti tecnici: p<0.0001), sex (males versus females p<0.0001), interest (not versus yes: p=0.002). CONCLUSIONS: Teenagers are favourable towards all forms of living kidney donation. The lower prevalence of positive answers on acceptance versus donation suggests that fears of endangering the donor's health may be one of the causes for a low living donation rate in our setting. The mixed answers on mercenary donation suggest discussing this complex issue in future educational programs.