Report of a case of discoid lupus erythematosus localised to the oral cavity: immunofluorescence findings.

Discoid Lupus Erythematosus (DLE) is a chronic disease with a typical cutaneous involvement. This pathology rarely involves mucosa: oral cavity is interested in 20 percent of DLE patients. We describe a case of oral DLE in a 50-year-old woman with an anamnesis for autoimmune disorders. This study shows the helpful role of immunofluorescence in the diagnosis of autoimmune diseases. The first diagnostic step was the clinical observation of the oral mucosa: the lesion area was erythematous, atrophic and hyperkeratotic. The patient then underwent laboratory examination. We utilized human epithelial cells (Hep-2010) for Indirect Immuno-Fluorescence (IIF). Moreover, the biopsy site for Direct Immuno-Fluorescence (DIF) and histopathological analysis was the untreated oral lesion. IIF detected an increase of Anti-Nuclear Antibody (ANA) and positivity for SSA-RO. By DIF, we observed IgG/IgA/fibrinogen along basal layer. Multiple biopsies reported signs of chronic basal damage. Steroid systemic therapy induced a considerable lesion regression. We suggest the use of immunofluorescence with the integration of further data to improve diagnosis of rare diseases and to establish a suitable therapy.

Antibiotic treatment for acute 'uncomplicated' or 'primary' pyelonephritis: a systematic, 'semantic revision'.

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.

Drug use and kidney donation: what are high-risk behaviors today?

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.

Is male homosexuality still a cultural taboo for kidney donation?

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.

Diagnostic accuracy of the serum profile of gastric mucosa in relation to histological and morphometric diagnosis of atrophy.

BACKGROUND: Histology is the gold standard for diagnosis of atrophy but is hampered by observer variation. A reliable method to overcome this issue is morphometric analysis of gastric mucosa. Serum pepsinogens and gastrin have been proposed in the diagnostic work-up of gastric atrophy although diagnostic accuracy of these tests is considered unsatisfactory. AIM: To evaluate the diagnostic accuracy of gastric serum profile in relation both to morphological and morphometric diagnosis of gastric atrophy. METHODS: Ninety-four dyspeptic out-patients underwent upper endoscopy and evaluation of serum levels of PGI, PGII and 17-gastrin. Diagnostic accuracy of gastric serum profile was tested by receiver operating characteristic curves and by evaluation of sensitivity and specificity in relation to both histology and morphometric analyses. RESULTS: As far as concern to histological evaluation, only PGI/PGII ratio showed an acceptable diagnostic accuracy in discrimination of gastric atrophy, while, when morphometric analysis was considered as reference, both serum PGI level and PGI/PGII ratio showed an excellent performance. However, both PGI and PGI/PGII ratio showed low sensitivity and high specificity. CONCLUSIONS: Serological gastric profile corresponds better with the morphometric diagnosis of atrophy, even if, because of the low sensitivity, today this could only be used as screening test of chronic atrophic gastritis.

Play-back theatre, theatre laboratory, and role-playing: new tools in investigating the patient-physician relationship in the context of continuing medical education courses.

AIM: The aim of this study was to report on the validation of a role-playing approach, using play-back and theatre laboratory in the context of a continuing medical education (CME) course on predialysis and transplantation, to discuss the patient-physician relationship. METHODS: The course was developed with the help of a theatre director. The role-playing 2-day course was designed to be highly interactive for a small group (15-20 participants), based on a core of case reports (dialysis, transplantation, and return to dialysis after graft failure). Two stages were included: play-back theatre in which experiences told by the participants were mimed by a group of actors, and theatre laboratory in which different aspects of voice and touch were explored. Opinions were gathered by an anonymous semistructured questionnaire completed by all participants. RESULTS: The course obtained a high score from The Ministry of Health (14 credits, 1 per teaching hour). The opinions of the 18 participants were highly positive; all liked the courses. Sixteen of 18 asked to repeat the experience. The strong emotional involvement was an advantage for 15 of 18, sharing emotional aspects of the profession for 10 of 18, and usefulness in clarifying opinions on "dark sides" of our profession for 10 of 18. CONCLUSION: The positive opinions recorded during this experience, the first experiment with a "psycho-theatrical approach" developed in a CME course in our country, suggest the benefit of implementing nonconventional, educational approaches in a multidisciplinary discussion of the patient-physician relationship in transplantation medicine.

Diffuse vascular damage in a transplanted kidney: an indication for nuclear magnetic resonance?

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.

CKD patients and erythropoietin: do we need evidence-based informed consent?

BACKGROUND: Consent to therapy is increasingly requested in the form of ''informed consent''. OBJECTIVE: To validate an evidence-based informed consent form for erythropoietin (EPO) therapy and to evaluate patient opinions about the informed consent approach. METHODS: An evidence-based informed consent form was developed as part of the Evidence-Based-Medicine course at the Medical School of Turin, Italy. It was validated by anonymous questionnaires (0-10 analogical scales and open answers) administered to patients at different stages of CKD (19 pre-ESRD, 26 hemodialysis, 12 transplant patients) attending an outpatient unit of the University of Turin, to 8 nurses, and to 26 medical students. RESULTS: All individuals filled in the questionnaire. Interest in a detailed explanation of the therapy was high (median 9), as was comprehension (median 9), with no differences between patients with regard to disease stage (pre-ESRD vs. RRT) or educational level. Prior knowledge of the therapy was affected by the educational level (p=0.013 for the advantages and p=0.004 for the side effects) and the professional role (patients vs caregivers: p=0.009 for the advantages and p<0.001 for side affects); patient knowledge of the advantages (median 6) tended to increase as the disease progressed (p=0.015). The most common response by patients was that informed consent was necessary for all drugs (35.1%); 73.1% of the caregivers considered it necessary only for severe side effects. The preferred modality of consent was discussion with the caregiver during the clinical controls (42% of all cases). CONCLUSIONS: Patient interest in and comprehension of an informed consent form with a detailed explanation of the therapy was high; the caregiver's opinion was still the most valued teaching tool.

Is there a link between environmental factors and a genetic predisposition to cancer? A lesson from a familial cluster of gastric cancers.

To determine the prevalence of gastric precancerous lesions and mucosal genetic alterations in relatives of a cluster of familial gastric cancer (FGC), we studied a kindred spanning two generations. The founder, daughter and niece underwent surgery for gastric cancer (GC); a son and other two daughters of the founder, presented with chronic dyspepsia. In all subjects, gastric mucosa samples were analysed for pathological features, Helicobacter pylori infection, microsatellite (MIN) and chromosomal (CIN) instability. The overexpression of mp53 and c-myc, and cytoplasmic beta-catenin delocalisation were found in the 2 younger cancer patients. All GC and gastritis patients had normal E-cadherin expression and were MIN-negative. Aneuploidy characterised all GC cases, and mixed euploid and aneuploid cell populations were present in the gastric biopsies from two of three 'at-risk' relatives. These two subjects, one of whom had severe active gastritis, and gastric mp53 and c-myc expression, were CagA-positive H. pylori-infected. DNA aneuploidy, p53 and c-myc expression disappeared after H. pylori eradication. In this FGC cluster, genetic abnormalities were found in first-degree relatives (3 patients) only in presence of H. pylori infection (2 cases H. pylori-positive versus 1 case H. pylori-negative) supporting the hypothesis that, besides the influence of a genetic profile, FGC may be, at least partly, mediated by intrafamilial clustering of H. pylori infection.

Overexpression of cyclin-D1, bcl-2, and bax proteins, proliferating cell nuclear antigen (PCNA), and DNA-ploidy in squamous cell carcinoma of the oral cavity.

The prognostic role of the expression of bcl-1, bcl-2, bax, PCNA, and DNA-ploidy in a series of 25 oral squamous cell carcinoma (SCC) was investigated. The average age of the patients was 62.04 years (range, 27 to 81 years), with a sex ratio (M/F) of 23:2. The follow-up mean time was 2.24 years (range, 8 months to 8 years from surgery). Immunohistochemistry for PCNA, bcl-2, bcl-1, and bax proteins was carried out on 5-microm serial sections from formalin-fixed, paraffin-embedded tissue. The findings were compared with clinicopathologic data and with follow-up. The statistical evaluation of the results of the current study suggests that the low positivity for PCNA with a high positivity for bcl-2 protein are related to a better clinical behavior of the tumors. By converse, a high expression of PCNA, bax, and bcl-1 appears to correlate with a worse prognosis. All of our cases of SCC showed the presence of aneuploid populations, which was not correlated with the clinicopathologic parameters or with the overexpression of bcl-1, bcl-2, bax, and PCNA. Therefore, the aneuploidy per se did not predict the clinical evolution for the single cases of cancers. Nevertheless, once the parameters considered for the evaluation of DNA were examined in detail, it appeared that some of them, individually or combined with each other or with the expression of bcl-1, bcl-2, and bax, gained statistical significance in predicting the clinical evolution of SCC of our series. Particularly, high values of 2cDI and DNA-MG and the absence or reduction of the euploid population were associated with a short interval between surgery and recurrence or death, and this significance persisted when the simultaneous presence of overexpression of bcl-1 was considered.

DNA ploidy and cyclin D1 expression in basal cell carcinoma of the head and neck.

Basal cell carcinomas (BCCs) may be subdivided into primary with a favorable biologic course (BCC1) and recurrent and/or metastatic (BCC2). No clear association between primary tumor location, histologic subtype, or other clinicopathologic variables and predisposition for BCC2 has been found. Histopathologic criteria are limited for prognostication. To identify prognostic factors useful for planning therapy, we studied cyclin D1 immunohistochemical expression, DNA ploidy, and epiluminescence light microscopic (ELM) patterns in 60 cases of BCC (30 BCC1 and 30 BCC2) in the head and neck region, half of which were hyperpigmented. Cyclin D1 was absent in 27 cases, expressed at low level in 4 cases, and overexpressed in 30 cases. Seven BCCs were euploid, 28 exhibited a mixed cellular population, and 25 were aneuploid. Among aneuploid tumors, hypodiploidy was found in 12. Among the 30 pigmented carcinomas, only 15 showed a typical ELM pattern. No association between pigmentation and more aggressive biologic behavior of BCC was found. These results and follow-up data seem to indicate that an unfavorable outcome can be predicted by hyperexpression of cyclin D1, aneuploidy, and an atypical ELM pattern for pigmented cases. A definite hypodiploid peak was associated with worse prognosis. The analysis of cyclin D1 expression and DNA ploidy may help identify BCC with an aggressive phenotype and a poor clinical outcome.

Prognostic value of apoptotic index in cutaneous basal cell carcinomas of head and neck.

Basal cell carcinoma (BCC) is the most common type of human cancer, often locally invasive, and following a benign clinical course. However, a proportion of BCCs do recur after treatment, causing extensive local tissue destruction, seldom metastasizing. Morphological methods to unequivocally distinguish the aggressive forms of these tumors (BCC2) from the ordinary ones (BCC1) have so far been lacking. Apoptosis, or programmed cell death, is thought to be important for the death of tumor cells in various stages of carcinogenesis. We analyzed the extent of apoptosis in BCCs of head and neck in a morphological, morphometric, and electron-microscopic study, to estabilish on a retrospective basis, the relative frequency of recurrence of tumors showing different apoptotic rates. We found that BCC1 showed lower apoptotic index (AI) than BCC2 [BCC1: AI from 2.03 to 10.45% (mean value: 5.98%) BCC2: AI from 21. 91 up to 43.82% (mean value: 39.82%)]. The morphometric analysis of both BCC1 and BCC2 revealed significant differences between the values concerning nuclear area, length, perimeter, and roundness of the apoptotic cells with respect to the 'viable' neoplastic cells. Electron-microscopy confirmed that the features of morphological apoptotic cells were characteristic of programmed cell death. We hypothesized that low apoptotic rates in BCC1 could be indicative of a good prognosis. In fact, this corresponded to an 'expansive' but not still invasive neoplastic state. In this phase, however, the tumor cells may constitute the target for genetic changes triggered by enviromental physical or chemical mutagenic agents, such as UV rays. BCC2, then, could be the result of newly selected mutated neoplastic cellular clones, with more aggressive biological behavior. The high apoptotic level found in BCC2 could thus be used as an indirect alarm signal from pathologists. This hypothesis seems to be supported by most of the current data in the literature and by the clinical outcome of BCC2 of our series. In our opinion, routine evaluation of apoptosis in BCCs could be proposed to facilitate their sub-classification, contributing toward the evaluation of the prospective outcome of the individual patients.

Morphometric study of nucleolar organiser regions (AgNOR) in HPV-associated precancerous lesions and microinvasive carcinoma of the oral cavity.

A morphometric study of silver-stained nucleolar organiser regions (NOR) was performed on histological sections from routinely paraffin-embedded blocks of 26 oral biopsy specimens (21 cases of leukoplakia consisting of 13 low, 4 moderate, 4 severe degree of dysplasia, and 5 cases of microinvasive carcinomas). In situ hybridisation (ISH) for HPV-DNA was performed on serial sections of the same samples. The following parameters were studied: V NOR (single AgNOR volume per nucleus), TV NOR (total AgNOR volume per nucleus), and R.I. (AgNOR's roundness index). The results highlight that not all the morphometric features of AgNORs allow the discrimination between lesions with dysplasia of low, moderate and severe degree and microinvasive carcinoma. TV NOR appeared useful, while the other morphometric parameters appeared statistically not significant i differentiating between the different lesions. These findings suggest that high values of TV NOR in oral dysplasia could represent a risk marker, identifying a subgroup of lesions with a worse prognosis, constituting then a possible indication for rigorous clinical management and/or for complex treatment of these HPV-associated preneoplastic lesions.

Effect of Helicobacter pylori infection on gastric cell proliferation and genomic instability in a paediatric population of southern Italy.

BACKGROUND: The incidence of gastric cancer is high in areas with a high prevalence of Helicobacter pylori infection. Cell transformation and tumour progression occur over a long period of time and markers of genomic instability usually precede morphological changes. AIM: To evaluate the effect of Helicobacter pylori infection on cell proliferation, DNA status and oncogene expression in children. PATIENTS AND METHODS: Morphometric and immunohistochemical techniques were used to analyse DNA content, p53 and c-myc oncogene expression and cell proliferation on gastric biopsies of 53 children (27 Helicobacter pylori-negative and 26 Helicobacter pylori-positive). RESULTS: Gastric mucosa was normal in 11% of Helicobacter pylori-positive and in 33% of Helicobacter pylori-negative subjects. Most children had chronic non-atrophic gastritis regardless of Helicobacter pylori infection, and only a minority of children affected by Helicobacter pylori had mild atrophic gastritis. Cell proliferation was significantly higher in children with Helicobacter pylori-positive gastritis than in those with Helicobacter pylori-negative gastritis. No metaplasia, dysplasia, p53 overexpression or altered DNA content was found in any child. Interestingly, 46% of children with and 29% without Helicobacter pylori infection had c-myc overexpression closely related to the cell proliferation rate. CONCLUSION: Helicobacter pylori infection in children may coexist with a normal gastric mucosa, and it is not associated with genomic instability markers in cases of chronic gastritis.

Henoch-Schönlein purpura after 20 years of renal replacement therapy.

While the clinical impact of the impaired immune response, commonly described in chronic dialysis patients, is still a matter of discussion, it is usually considered that immunological diseases tend to become progressively less active after the start of regular renal replacement therapy (RRT). We reported a case of Henoch-Schonlein Purpura in a 51-year-old male, on RRT for 20 years, 8 on dialysis and 12 with renal graft, because of ESRD of unknown origin (chronic glomerulonephritis?). The acute onset of the syndrome, presenting purpuric rash, abdominal discomfort and asymmetric joint pain with edema and local signs of acute inflammation, was followed by several relapses over a 2 years period. This biopsy proven diagnosis offered an explanation for his chronic renal failure; furthermore, we conclude that, possibly because of the usually good correction of uremic immunodepression by efficient dialysis (this patient's Kt/V ranged from 1.1 to 1.3 according to Lowrie's formula), the possibility of immune diseases should be carefully considered even in long long-term RRT patients.

Modelling the "ideal" self care--limited care dialysis center.

Limited care dialysis is an interesting option, which has gained attention in several settings because of the aging of the uremic cohort. The aim of this study was to assess its potential in the Piedmont region in northern Italy, evaluating patients' and care-givers' preferences and testing them in a mathematical model of organisation. The study was conducted in the satellite unit of a university hospital (200-210 dialysis patients), following 35 patients (15 at home, 20 in the center, 10 on daily dialysis). Opinions were collected with a questionnaire and features identified were empirically tested through a simulation model. Most patients (34/35) preferred a small unit, with a stable caring team. Further options were flexibility of dialysis schedule, multiple treatment options, integrated center/home care. These needs could be met by a flexible organization including conventional dialysis (3/week) and daily dialysis (6/week). We employed a simulation model (ARENA software) to calculate the nurses required for each shift and the opening hours and best schedule for the unit. Addition of daily dialysis (2-3 hours) to two conventional 4-5 hour sessions to increased the number of patients followed or "spared" beds, ensuring flexibility. According to patients' best choice (7 dialysis stations), and to the recorded calls, the needs are for two nurses per shift, two shifts per day and six nurses for up to 30 patients in limited care. In conclusion, small centers with flexible schedules can tailor dialysis to patients' needs. A managerial approach is valuable for testing cost/benefit ratios in specific contexts.

Asclepiad's cock: a patient-physician association is a useful tool for educational programs in nephrology, dialysis, and transplantation.

BACKGROUND: The negative impact of the mass media, the lack of information, and the request for in-depth knowledge are the basis for the present need for educational programs on transplantation, brain death, and chronic kidney diseases end-stage renal disease; (ESRD). The aim of the present article was to critically review the activities performed by Il Gallo di Esculapio, a nonprofit association, in the education on the different phases of ESRD. The associates are physicians and patients, and the activities are integrated institutionally. METHODS: This report is a narrative review of the material produced and performed by Il Gallo di Esculapio ONLUS in 1996-2004. RESULTS: The two main activities developed were book writing and an educational program. Eight books for patient education were written on different aspects of dialysis, transplantation, and ESRD. Most were designed as theses of the Medical School. Cooperation with patients was important in all cases and fundamental for the collection of interviews. EDUCATION: A 4-hour educational program on transplantation started in 2000-2001 (1 high school was involved). The checklist originally included only transplantation and organ donation, but progressively gave space also to dialysis, ESRD, and social health care problems. In 2003-2004 the program involved 67 high schools. The association coordinated progressive patient involvement. CONCLUSION: Small, nonprofit patient-physician associations linked with the University allow enrolling resources for educational activities to often-neglected parts of the medical profession.

Tailored dialysis start may allow persistence of residual renal function after graft failure: a case report.

BACKGROUND: Restarting dialysis after kidney transplantation is a critical step with psychological and clinical implications. Maintenance of residual renal function a known factor affecting survival in chronic kidney disease, has so far not been investigated after a kidney transplantation. THE CASE: A 54-year-old woman who started dialysis in 1974 (first graft, 1975-1999) received a second "marginal" kidney graft in February 2001 (donor age, 65 years). Her chronic therapy was tacrolimus and steroids. She had a clinical history as follows: nadir creatinine level of 1.5 mg/dL, moderate-severe hypertension, progressive graft dysfunction, nonresponsiveness to addition of mycophenolate, tapering FK levels, and a rescue switch from tacrolimus to rapamycin. From October to December 2003, the creatinine level increased from 2-2.8 to 7 mg/dL. Biopsy specimen showed malignant and "benign" nephrosclerosis, posttransplantation glomerulopathy, and tacrolimus toxicity. Chronic dialysis was started (GFR <3 mL/min). Rapamycin was discontinued. Dialysis was tailored to reach an equivalent renal clearance of >15 mL/min (2 sessions/wk). Blood pressure control improved, nephrotoxic drugs were avoided, and fluid loss was minimized (maximum 500 mL/hr). By this policy, renal function progressively increased to GFR >10 mL/min in May 2004, allowing a once or twice weekly dialysis schedule, with good clinical balance, and obvious advantages for the quality of life. CONCLUSION: This long-term patient, who restarted dialysis with severely reduced renal function, regained sufficient renal function to allow once weekly dialysis. Thus, careful tailoring of dialysis sessions at the restart of dialysis may allow preservation of residual kidney function, at least in individuals for whom a subsequent graft is unlikely.

Opinions on renal transplantation and organ donation in high school students in two large northern (Torino) and southern (Napoli) Italian cities.

UNLABELLED: Organ shortage for transplantation has focused attention on educational interventions. Italy is a nonhomogenous country whose cultural and economic differences are reflected in the health-care system: dialysis is mainly public in the north versus private in the south; and transplantation rates display a wide range from 3.4 to 37.8 per million people in 2002. The aim of the present study was to analyze the opinions of population of high school students (last two years) in two large cities: northern (Torino) and southern (Napoli) Italy, as a knowledge base for a randomized controlled trial on the efficacy of educational interventions on renal replacement therapy and organ donation, targeted to high school students. METHODS: This preliminary study included eight public high schools that completed a first and anonymous semistructured questionnaire. Five hundred and eighty nine questionnaires were retrieved in Torino and 539 in Napoli. In both cities most students answered that they would give a kidney to a brother, sister, or partner needing dialysis (Torino: yes 80.6%; no 2.2%, uncertain-blank 17.2%; Napoli: yes 86.1%, no 1.1%; uncertain-blank 12.8%). Only 36.3% of the students in Torino and 37.7% in Napoli answered that they would consent to organ donation, if they had to choose for a strict relative with brain death. Opposition was 28% in Torino and 23.7% in Napoli; 35.7% in Torino and 38.6% in Napoli were blank-uncertain. These data underline the need for detailed information on the opinions of the overall population as basis for tailored educational campaigns.

Efficacy of an educational program on dialysis, renal transplantation, and organ donation on the opinions of high school students: a randomized controlled trial.

AIM: Organ shortage is a rate-limiting factor for transplantation. The aim of this study was to evaluate the impact of an educational program targeted to high school students on opinions concerning organ donation. METHODS: Sixteen public high schools in Torino, Italy, were randomized (2001 to 2002) as interventions (n = 8) or controls (n = 8). Intervention was composed of first questionnaire, first lesson (one to two classes; 2 hours, by a trained nephrology fellow); second lesson (all classes together; coordinated by a nephrologist, with patients and trainees); second questionnaire. Control included questionnaires. Statistical analysis compared the opinions in the questionnaires after stratification for age, sex, and type of school. RESULTS: Fourteen schools completed the program (seven interventions: 937 first and 808 second questionnaires; controls: 739 and 659). Television (82.5%) and newspapers (43.2%) were the main sources of information; knowledge on renal transplantation (grafts feasible per patient, average duration) was low; only 12.2% of the students gave correct answers. The opinions on living donation were highly positive (76.8%) with no difference in control, intervention schools, first and second questionnaires, according to sex, age, or type of school. The opinions on cadaveric transplantation were affected by the educational intervention with a drop in negative answers (from 33.7% to 16%), with an increase in positive (from 31.5% to 42.9%) and in uncertain ones (from 34.8% to 41.1%) among the intervention schools; 98% of the students appreciated the program. CONCLUSION: The positive effect on student opinions suggests the need to develop educational approaches as a part of our routine clinical work.