Physical Exercise in Kidney Renal Recipients: Where have We Come.

Background Kidney transplantation constitutes the most effective therapeutic option for patients suffering from end-stage renal disease but remains burdened by a high incidence of cardiovascular disease. To date, exercise is an important preventive strategy that has been underestimated; in kidney transplant patients exercise programs leads to an improvement in cardiorespiratory performance, muscle strength, arterial stiffness and patients' quality of life perception. Summary The nephrology and transplant community have moved from generic suggestions to specific indications regarding Frequency, Intensity, Time, Type, Volume, and Progression of physical exercise both in the pre- and post-transplant phase. The latest guidelines from the World Health Organization for patients with chronic conditions propose a combination of aerobic, muscle strengthening and multicomponent exercises (e.g. balance) to improve health. Based on recent evidence, a combined exercise program (aerobic and strength exercise) is largely proposed to kidney transplant recipients. Aerobic exercise should be performed at an intensity >60% of theoretical maximum heart rate or maximum oxygen uptake possibly every day, strength training should be performed at a >60% the estimate single Maximum Repetition, at least 2 times per week. Key Messages Physical exercise should be personalized in relation to the patient's baseline performance; increases must be progressive and gradual. Regular physical activity should also be recommended to patients awaiting for a transplant. Eventually, an organizational models based on a network of Nephrology Units, Transplant Centers, Sports Medicine Centers and fitness center or outdoor gym are essential elements for overcoming the logistical barriers for prescribing and carrying out regular physical activity.

Upper-Body Resistance Exercise Reduces Time to Recover After a High-Volume Bench Press Protocol in Resistance-Trained Men.

ABSTRACT: Bartolomei, S, Totti, V, Griggio, F, Malerba, C, Ciacci, S, Semprini, G, and Di Michele, R. Upper-body resistance exercise reduces time to recover after a high-volume bench press protocol in resistance-trained men. J Strength Cond Res 35(2S): S180-S187, 2021-The aim of this study was to compare the effects of active and passive strategies on the recovery response after a high-volume bench press protocol. Twenty-five resistance-trained men (mean ± SD: age = 25.8 ± 3.6 years; body mass = 87.1 ± 12.1 kg; and height = 177.4 ± 4.9 cm) performed a high-volume bench press session (8 sets of 10 reps at 70% of 1 repetition maximum). Subsequently, they were randomly assigned to an active recovery (AR) group (n = 11) or to a passive recovery (PR) group (n = 14). Active recovery consisted of light bench press sessions performed 6 hours and 30 hours after the high-volume exercise protocol. Muscle performance (bench throw power [BTP] and isometric bench press [IBP]) and morphology (muscle thickness of pectoralis major [PECMT] and of triceps brachii [TRMT]) were measured before exercise (baseline [BL]), and at 15-minute (15P), 24-hour (24P), and 48-hour (48P) post-exercise. Post-exercise recovery of both maximal strength and power was accelerated in AR compared with PR. Both BTP and IBP were significantly (p < 0.001) reduced at 15P and 24P in PR, whereas changes were significant (p < 0.001) at 15P only in AR. PECMT was still significantly (p = 0.015) altered from BL at 48P in PR, whereas changes were significant (p < 0.001) at 15P only in AR. No significant interactions (p > 0.05) between PR and AR were detected for TRMT and muscle soreness. The present results indicate that AR enhances the recovery rate after high-volume exercise sessions and may be included in resistance training programs to optimize muscle adaptations.

Physical activity and renal function in the Italian kidney transplant population.

BACKGROUND: The well-documented benefits of physical activity (PA) are still poorly characterized in long-term kidney transplant outcome. This study analyzed the impact over a 10-year follow-up of PA on graft function in Italian kidney transplant recipients (KTRs). METHODS: Since 2002, the Italian Transplant-Information-System collected donor and recipient baseline and transplant-related parameters in KTRs. In 2015, 'penchant for PA' (PA ≥ 30-min, 5 times/week) was added. Stable patients aged ≥18 years at the time of first-transplantation were eligible. KTRs with at least 10-year follow-up were also analyzed. Mixed-effect regression models were used to compare eGFR changes over time in active versus non-active patients. RESULTS: PA information was available for 6,055 KTRs (active 51.6%, non-active 48.4%). Lower penchant for PA was found in overweight and obese patients (OR = 0.84; OR = 0.48, respectively), in those with longer dialysis vintage (OR = 0.98 every year of dialysis), and older age at transplant. Male subjects showed greater penchant for PA (OR = 1.25). A slower decline of eGFR over time was observed in active KTRs compared to non-active, and this finding was confirmed in the subgroup with at least 10-year follow-up (n = 2,060). After applying the propensity score matching to reduce confounding factors, mixed-effect regression models corroborated such better long-term trend of graft function preservation in active KTRs. CONCLUSIONS: Penchant for PA is more frequent among male and younger KTRs. Moreover, in our group of Italian KTRs, active patients revealed higher eGFR values and preserved kidney function over time, up to 10-years of follow-up.

Longitudinal Analysis of Cardiovascular Risk Factors in Active and Sedentary Kidney Transplant Recipients.

Background: Despite the benefits of physical activity on cardiovascular risk in kidney transplant recipients (KTRs), the long-term effects of exercise have been poorly investigated. This is a three-year observational study comparing graft function and cardiovascular risk factors in active KTRs (AKTRs) vs. sedentary KTRs (SKTRs). Methods: KTRs with stable renal function were assigned to active or sedentary group in relation to the level of daily physical activity based on World Health Organization (WHO) recommendations (<150 or >150 minutes/week, respectively). Complete blood count, renal function indices, lipid profile, blood pressure and anthropometric measures were collected yearly for an observation period of three years. The comparisons between the two groups were performed by repeated measures analyses of covariance (ANCOVAs), with age as a covariate. Results: Fifty-four subjects were included in the study. Thirty of them were identified as AKTRs (M/F 26/4, aged 45 ± 12 years) and 24 as SKTRs (M/F 18/6, aged 51 ± 14 years). Baseline characteristics were similar between the groups except body mass index (BMI) that was significantly higher in SKTRs (p = 0.043). Furthermore, over the three-year observation period, BMI decreased in AKTRs and increased in SKTRs (p = 0.006). Graft function was stable in AKTRs, while it showed a decline over time in SKTRs, as indicated by the rise in serum creatinine levels (p = 0.006) and lower eGFR (p = 0.050). Proteinuria, glucose and uric acid levels displayed a decrease in AKTRs and an increase in SKTRs during the three-year period (p = 0.015, p = 0.004 and p = 0.013, respectively). Finally, concerning lipid profiles, AKTRs had a significant reduction over time of triglycerides levels, which conversely showed a clinically relevant increase in SKTRs (p = 0.014). Conclusions: Our findings indicate that regular weekly exercise training may counteract the increased cardiovascular risks and also prevent graft function decline in KTRs.

Health-related quality of life after solid organ transplantation: the role of sport activity.

The aim of the study was to investigate the effects of sport activity on health-related quality of life (HRQoL) of solid organ transplant recipients participating in sports competitions. A group of 168 sportive transplanted patients (STP), a group of 97 nonsportive transplanted patients (NSTP), and a group of 152 sportive healthy controls (SHC) were compared on the eight scales of the SF-36 questionnaire. STP and NSTP reported significantly lower scores than SHC on the physical functioning scale. STP did not differ from SHC in the Role-Physical, General Health, and Vitality scales, while NSTP reported significantly lower scores. STP obtained higher scores than NSTP and SHC on Mental Health. Among STP, the effect of quantity of sport activity was significant on General Health and Role Emotional, with more sport activity associated with higher HRQoL. Organ failure and post-transplant therapies may have negative consequences on HRQoL. Sports activities and participation in sports competitions can reduce this impact, improving general and psychological functioning of solid organ transplant recipients.

Physical activity in solid organ transplant recipients: preliminary results of the Italian project.

BACKGROUND/AIMS: The role of physical activity in transplanted patients is often underestimated. We discuss the Italian National Transplant Centre experience, which started in 2008 studying transplanted patients involved in sports activities. The study was then developed through a model of cooperation between surgeons, sports physicians and exercise specialists. METHODS: A multicentre study was realized in 120 transplanted patients of which 60 treated with supervised physical activity (three sessions/week of aerobic and strengthening exercises) and 60 controls. We present the results of the first 26 patients (16 males, 10 females; 47.8 ± 10.0 years; 21 kidney, 5 liver transplanted; time from transplant 2.3 ± 1.4 years) who completed 12 months of supervised physical activity. RESULTS: Data showed an increase of peak aerobic power (t=4.535; P<0.01) and maximum workload (t=4.665; P<0.01) in the incremental cycling test. Maximum strength of knee extensors (t=2.933; P<0.05) and elbow flexors (t=2.450; P<0.05), and the power of lower limb (t=2.303; P<0.05) significantly increases. Health Related Quality of Life showed a significant improvement. Serum creatinine (1.4 ± 0.5 vs 1.3 ± 0.4 mg/dL) and proteinuria (0.10 ± 0.14 vs 0.08 ± 0.08 gr/dL) were stable. CONCLUSION: These preliminary results confirm the positive effects of supervised physical exercise. It can be considered as an input to promote other detailed exercise protocols.

Effects of combined strength and endurance training on exercise capacity in kidney transplant cyclists and runners.

INTRODUCTION: After transplantation, engaging in regular physical activity (PA) or sport is recommended for health. Participation to competitive sports is increasingly common among kidney transplant recipients while little is known on how training affects the physical performance in transplanted athletes. AIM: The purpose of this case study was to assess the effects of a tailored training program on exercise parameters in kidney transplant cyclists (CKTRs) and runners (RKTRs). METHODS: Twelve male transplanted athletes were enrolled. The workload at aerobic and anaerobic thresholds, the submaximal aerobic power (V'O2 stage) and rate of perceived exertion (RPE) during an incremental cycling or running test, and the peak instantaneous force (PIF) during a countermovement jump were assessed at baseline (T0) and after 6 months of tailored training (T6) consisting in strength and aerobic exercises. Exercise adherence, blood lipid profile and renal function were also investigated. RESULTS: Eight CKTRs and 4 RKTRs completed the 6-month training period, with a significant increase of training volume (minutes/week). The exercise adherence was met by 90% in both groups. At T6, there were significant (p<0.05) improvements of maximum workload attained, the workload corresponding to the aerobic threshold and PIF, while workloads at anaerobic threshold, V'O2 stage and RPE were unchanged. Blood cholesterol significantly decreased (p<0.01), while the other blood parameters were unchanged. CONCLUSIONS: These findings indicate that the combined strength and endurance training is well tolerated and may improve exercise performance in this selected population of KTRs.

GDF15 Plasma Level Is Inversely Associated With Level of Physical Activity and Correlates With Markers of Inflammation and Muscle Weakness.

Growth differentiation factor 15 (GDF15) is a stress molecule produced in response to mitochondrial, metabolic and inflammatory stress with a number of beneficial effects on metabolism. However, at the level of skeletal muscle it is still unclear whether GDF15 is beneficial or detrimental. The aim of the study was to analyse the levels of circulating GDF15 in people of different age, characterized by different level of physical activity and to seek for correlation with hematological parameters related to inflammation. The plasma concentration of GDF15 was determined in a total of 228 subjects in the age range from 18 to 83 years. These subjects were recruited and divided into three different groups based on the level of physical activity: inactive patients with lower limb mobility impairment, active subjects represented by amateur endurance cyclists, and healthy controls taken from the general population. Cyclists were sampled before and after a strenuous physical bout (long distance cycling race). The plasma levels of GDF15 increase with age and are inversely associated with active lifestyle. In particular, at any age, circulating GDF15 is significantly higher in inactive patients and significantly lower in active people, such as cyclists before the race, with respect to control subjects. However, the strenuous physical exercise causes in cyclists a dramatic increase of GDF15 plasma levels, that after the race are similar to that of patients. Moreover, GDF15 plasma levels significantly correlate with quadriceps torque in patients and with the number of total leukocytes, neutrophils and lymphocytes in both cyclists (before and after race) and patients. Taken together, our data indicate that GDF15 is associated with decreased muscle performance and increased inflammation.

Bioelectrical impedance vector analysis (BIVA) in renal transplant recipients during an unsupervised physical exercise program.

BACKGROUND: Muscle weakness, incorrect body water distribution and reduced exercise tolerance are the main characteristics found in renal transplant recipients after surgical treatment. Regular physical supervised exercise programs, at moderate intensity, have been promoted to contrast these aspects, while few data are available for long-term unsupervised mixed exercise plans. Bioelectrical impedance vector analysis (BIVA) provides a semi-quantitative evaluation of body cell mass and body water. This study aims to approach the role of the BIVA analysis in the follow-up of Renal Transplant Group (RTG) and analyze the impact of unsupervised exercise program. METHODS: Thirteen male RTG and ten healthy subjects, adherent to a tailored exercise program, at moderate intensity and prescribed in an unsupervised way, have been followed up for one year. Every six months all the subjects have been submitted to the ergometric test, echocardiographic exam and an analysis of body composition by bioimpedance. They were compared to a healthy control group (HG). RESULTS: A significant reduction of the BMI was observed at the end of the study in the RTG group (T0 24.8±3.2, T12 24.2±3.2 kg/m2; P<0.05). BIVA has shown a lower right quadrant for RTG. All echocardiographic parameters were in a normal range, and no differences were found over time. CONCLUSIONS: Unsupervised tailored and mixed exercise intervention reduces some cardiovascular risks factors. However, it does not modify the frailty of RTG. BIVA analysis seems to have appropriate sensitivity to highlight this aspect.

Observational Retrospective Study on Patient Lifestyle in the Pretransplantation and Post-transplantation Period in the Emilia-Romagna Region.

INTRODUCTION: Despite the well-known benefits of exercise during the pretransplantation and post-transplantation phases, adherence to active lifestyles is still reduced. The aim of the present study is to evaluate how many patients who have received organ transplants and candidates for organ transplantation carry out physical or sports activities in order to increase adherence to an active lifestyle. METHODS: The patients who agreed to participate in the study were interviewed about their lifestyle habits by the staff at the nephrology, dialysis, and hepatology units of the Emilia-Romagna region. The interview investigated the patient's lifestyle (active or sedentary) and type of physical activity (walking, cycling, gardening, gym at least 3 to 40 minutes, 2 to 3 times per week) or sport (training > 2 times per week) routinely practiced. RESULTS: We collected 1138 interviews from patients on the waiting list (n = 159) for organ transplant, those with kidney transplants (n = 756), and those with liver transplants (n = 223) monitored in the Emilia-Romagna hospitals (regional patients 67%, extraregional 33%). Eighty-four patients on the waiting list for a transplant (kidney) were sedentary, 75 practiced physical activity, and 10 of 75 physically active patients practiced sport. Four hundred fifteen patients with kidney transplants were sedentary, 341 practiced physical activity, and 31 of 341 physically active patients practiced sport. Among patients with liver transplants, 56 were sedentary, 167 practiced physical activity, and 20 of 167 physically active patients played sport. CONCLUSIONS: In-line with the general population, we confirmed a high tendency toward a sedentary lifestyle (44% of respondents) among patients with organ transplants and those on waiting lists for organ transplants. Including a prescription for physical exercise as part of the therapeutic regimen can be useful for changing lifestyles during the pre- and post-transplantation period.

A Comparison between the Recovery Responses Following an Eccentrically Loaded Bench Press Protocol Vs. Regular Loading in Highly Trained Men.

The purpose of this study was to compare the physiological responses of a single bout of an eccentric accentuated bench press protocol (120% of 1RM in the eccentric phase/80% in the concentric phase; [120/80]) versus a regular high-intensity exercise protocol (80%/80%; [80/80]) in resistance-trained men. Eleven men (age = 25.6 ± 3.9 y; body mass = 84.6 ± 11.2 kg; body height = 176.4 ± 3.9 cm) with 6.3 ± 3.4 y of resistance training experience performed each protocol in counterbalanced, randomized order. Isometric, isokinetic and ballistic tests were performed at the bench press (IBPF, ISOK and BTP, respectively) at baseline (BL), 15-min (15P), 24-h (24P), and 48-h (48P) post-exercise for each testing session. In addition, muscle thickness of the pectoralis major (PecMT) was measured at the same timepoints via ultrasound. Significantly greater reductions in BTP (p < 0.001), peak force during both ISOK (p = 0.005) and IBPF (p = 0.006) at 15P were detected in 120/80 compared to 80/80. BTP was still significantly (p = 0.009) impaired at 48P following the 120/80 protocol, while no differences were noted following 80/80. PecMt was significantly elevated following both 120/80 and 80/80 (p < 0.05) at 15P, but significant differences between the trials were present at 15P and 24P (p = 0.005 and p = 0.008, respectively). Results indicated that heavy eccentric loading during the bench press exercise caused greater performance deficits than a bout of traditionally loaded high intensity resistance exercise. Power performance appears to be more influenced by the 120/80 protocol than isometric peak force. Eccentrically loaded exercise sessions should be separated by at least 48 hours to obtain a complete recovery of the initial muscle morphology and performance.

Promotion of Pre- and Post-Transplant Physical Exercise in the Emilia-Romagna Region: The Network of the Program "Transplantation, Physical Activity, and Sport".

BACKGROUND: Following the positive experience of the national project "A transplant...and now it's time for sport," the Transplant Reference Center of the Emilia-Romagna Region has pursued the promotion of pre- and post-transplant physical exercise by developing a network. METHODS: The path involved the transplant centers and operative units (UU.OO) who wanted to target transplant and waiting list patients, who are clinically stable, to perform personalized exercise through a program (supervised or not) prescribed by a specialist in sports medicine. With the collaboration of the Collective Prevention and Public Health Service, the network was established, consisting of the sports medicine centers and the gyms that promote health for adapted physical activity (PS-AMA). To implement the network, training courses for all the professionals involved (doctors, nurses, exercise specialists) and operational meetings in the transplant centers-nephrology units with patients' associations have been organized. RESULTS: To date, there are 14 transplant centers and UU.OO, 9 sports medicine centers, and 45 PS-AMA involved in this network. Seven training courses were organized with the participation of 193 health professionals. Since January 2016, there have been 65 transplanted patients and 5 patients on the waiting list who practice the prescribed exercise. Of these, 45 carry out supervised exercise in PS-AMA; 25 perform autonomous exercise. Each patient is monitored every 6 months. No problems related to the exercise performance were recorded. CONCLUSIONS: The development of a network of professionals and associations is the key element to raise awareness of physical activity among transplanted and waiting-for-transplant patients, reducing the pathologies associated with a sedentary lifestyle.

Physical Condition, Glycemia, Liver Function, and Quality of Life in Liver Transplant Recipients After a 12-Month Supervised Exercise Program.

BACKGROUND AND AIMS: Despite the excellent long-term outcomes in liver transplant (LT) recipients, several medical complications related to lifestyle still represent an issue. This study examined the effects of a 12-month supervised aerobic and strength training program on the aerobic capacity, muscle strength, metabolic profile, liver function, and quality of life of a cohort of LT recipients. METHODS: LT recipients with stable liver function were assigned to interventional exercise (group A) or usual care (group B). Aerobic capacity, muscle strength, metabolic profile, liver and kidney function, and health-related quality of life were assessed at baseline and after 6 and 12 months. Group A attended supervised training sessions 3 times per week for 12 months. Group B received general recommendations about home-based exercise. RESULTS: Forty patients from 6 Italian LT centers were randomized. Twenty-nine (72.5%, men-to-women ratio 23:6, mean age, 52 ± 8 years) LT recipients completed the study. Baseline characteristics were similar between groups except for body mass index and time from LT. No episode of acute rejection nor increase of transaminases occurred. Maximum workload and body mass index increased in both groups over time, but fasting glucose significantly decreased in group A (94.0 ± 15.0 mg/dL vs 90.0 ± 17.0 mg/dL; P = .037) and increased in controls (95.0 ± 24.0 mg/dL vs 102.0 ± 34.0 mg/dL, P = .04). Upper limb muscle strength increased only in supervised LT recipients. Vitality and general and mental health domains significantly improved after physical exercise. CONCLUSIONS: Supervised combined training was safe and effective in increasing aerobic capacity, muscle strength, and quality of life and in improving glucose metabolism in stable LT recipients.

Renal function and physical fitness after 12-mo supervised training in kidney transplant recipients.

AIM: To evaluate the effect of a 12-mo supervised aerobic and resistance training, on renal function and exercise capacity compared to usual care recommendations. METHODS: Ninety-nine kidney transplant recipients (KTRs) were assigned to interventional exercise (Group A; n = 52) and a usual care cohort (Group B; n = 47). Blood and urine chemistry, exercise capacity, muscular strength, anthropometric measures and health-related quality of life (HRQoL) were assessed at baseline, and after 6 and 12 mo. Group A underwent a supervised training three times per week for 12 mo. Group B received only general recommendations about home-based physical activities. RESULTS: Eighty-five KTRs completed the study (Group A, n = 44; Group B, n = 41). After 12 mo, renal function remained stable in both groups. Group A significantly increased maximum workload (+13 W, P = 0.0003), V'O2 peak (+3.1 mL/kg per minute, P = 0.0099), muscular strength in plantar flexor (+12 kg, P = 0.0368), height in the countermovement jump (+1.9 cm, P = 0.0293) and decreased in Body Mass Index (-0.5 kg/m2, P = 0.0013). HRQoL significantly improved in physical function (P = 0.0019), physical-role limitations (P = 0.0321) and social functioning scales (P = 0.0346). No improvements were found in Group B. CONCLUSION: Twelve-month of supervised aerobic and resistance training improves the physiological variables related to physical fitness and cardiovascular risks without consequences on renal function. Recommendations alone are not sufficient to induce changes in exercise capacity of KTRs. Our study is an example of collaborative working between transplant centres, sports medicine and exercise facilities.

Renal Function in Kidney and Liver Transplant Recipients After A 130-km Road Cycling Race.

BACKGROUND: A few patients, after receiving solid organ transplantation, return to performing various sports and competitions; however, at present, data no study had evaluated the effects of endurance cycling races on their renal function. METHODS: Race times and short form (36) health survey questionnaires of 10 kidney transplant recipients (KTR) and 8 liver transplant recipients (LTR) transplanted recipients involved in a road cycling race (130 km) were compared with 35 healthy control subjects (HCS), also taking laboratory blood and urine tests the day before the race, at the end of the race, and 18 to 24 hours after competing. RESULTS: The 3 groups showed similar race times (KTR, 5 hours 59 minutes ± 0 hours 39 minutes; LTR, 6 hours 20 minutes ± 1 hour 11 minutes; HCS, 5 hours 40 minutes ± 1 hour 28 minutes), similar short form (36) health survey scores, and similar trend of laboratory parameters which returned to baseline after 18 to 24 hours. After the race, there was an increase in creatinine (0.24 mg/dL; effect size [ES] = 0.78; P < 0.001), urea (22 mg/dL; ES = 1.42; P < 0.001), and a decrease of estimated glomerular filtration rate (-17 mL/min; ES = 0.85; P < 0.001). The increase of blood uric acid was more remarkable in HCS and KTR (2.3 mg/dL; ES = 1.39; P < 0.001). The KTR showed an increase of microalbuminuria (167.4 mg/L; ES = 1.20; P < 0.001) and proteinuria (175 mg/mL; ES = 0.97; P < 0.001) similar to LTR (microalbuminuria: 176.0 mg/L; ES = 1.26; P < 0.001; proteinuria: 213 mg/mL; ES = 1.18; P < 0.001), with high individual variability. The HCS had a nonsignificant increase of microalbuminuria (4.4 mg/L; ES = 0.03; P = 0.338) and proteinuria (59 mg/mL; ES = 0.33; P = 0.084). CONCLUSIONS: Selected and well-trained KTR and LTR patients can participate to an endurance cycling race showing final race times and temporary modifications of kidney function similar to those of HCS group, despite some differences related to baseline clinical conditions and pharmacological therapies. Patients involved in this study represent the upper limit of performance currently available for transplant recipients and cannot be considered representative of the entire transplanted population.

Acute obstructive jaundice: a possible clinical manifestation of IPMT. Case report and review of the literature.

INTRODUCTION: Pancreatic masses causing acute obstructive jaundice still pose diagnostic difficulties and their characterization can often be complex as there is significant overlap in their imaging features. CASE REPORT: We describe a case of Intraductal Papillary Mucinous Tumor (IPMT) presenting with acute obstructive jaundice in a patient with history of recurrent mild pancreatitis. Clinical evaluation, abdominal ultrasonography (US) and CT-scan posed suspicion of adenocarcinoma with cystic degeneration of the pancreatic head or mucinous cystadenocarcinoma; magnetic resonance (MR) with magnetic resonance cholangiopancreatography (MRCP) demonstrated the communication of the mass with the main pancreatic duct, posing differential diagnosis between main-duct-IPMT and mucinous cystadenocarcinoma. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated the presence of a mucus-secreting lesion inside duodenum and duodenal biopsies showed no evidence of neoplastic cells. RESULTS: The patient underwent spleen preserving total pancreatectomy that led to histological diagnosis of intraductal papillary mucinous with carcinoma in situ. DISCUSSION: The international guidelines for management of IPMT, reported in 2006 and revised in 2012, establish that the resectability and the absence of an invasive carcinoma are the most important prognostic factors in IPMT. Therefore an early diagnosis and a radical resection are crucial to improve the patient survival and reduce the recurrence rate. CONCLUSION: When an IPMT is suspected, the imaging modalities are essential to pose the diagnosis, maximise the chance to select the right surgical candidate and to perform the best treatment for each patient.