Percutaneous cutting balloon angioplasty for the treatment of renovascular hypertension in children and adolescents.

OBJECTIVE: Percutaneous transluminal renal angioplasty (PTRA), the recommended treatment in children with renovascular hypertension (RVH), often has unsatisfactory outcomes. Cutting balloons may improve the results of angioplasty in different vascular beds with complex and resistant lesions. We retrospectively analysed the effects of percutaneous cutting balloon angioplasty (PCBA) on blood pressure, cardiac mass and renal artery acceleration time in children/adolescents referred to our centre for RVH. PATIENTS AND METHODS: Thirteen patients (aged 9-19 years) with renal artery stenosis (RAS) and severe hypertension were identified. RASs were focal fibromuscular (FMD) or FMD-like dysplasia (in six cases bilateral, in five associated with mid aortic syndrome). Ten patients had uncontrolled hypertension, in nine cases associated with left ventricular hypertrophy (LVH). Acceleration time was abnormal in all stenotic arteries. Eighteen PCBA were performed, in three arteries associated with stent implantation. RESULTS: PCBA was technically successful in all individuals without major complications. In one patient, an intra-stent restenosis occurred, successfully redilated with conventional angioplasty without recurrence at 4 years distance. One year after PCBA, mean SBP and DBPs were markedly reduced from 146 ±â€Š25 to 121 ±â€Š10 mmHg and from 87 ±â€Š11 to 65 ±â€Š12 mmHg, respectively ( P  < 0.001 for both). At that time, hypertension was cured in seven children and controlled in five individuals. This favourable outcome was confirmed with ambulatory blood pressure measurement in four patients. At the latest follow-up, left ventricular mass and acceleration time were normal in all patients. CONCLUSION: PCBA proved to be a well tolerated and effective procedure that can be considered as an alternative to PTRA to treat hypertensive children/adolescents with recurrent or resistant RAS.

Kidney transplant in patients with atypical hemolytic uremic syndrome in the anti-C5 era: single-center experience with tailored Eculizumab.

RATIONALE AND OBJECTIVE: Patients with atypical hemolytic uremic syndrome (aHUS) have long been considered ineligible for kidney transplantation (KTx) in several centers due to the high risk of disease recurrence, graft loss and life-threatening complications. The availability of Eculizumab (ECU) has now overcome this problem. However, the best approach towards timing, maintenance schedule, the possibility of discontinuation and patient monitoring has not yet been clearly established. STUDY DESIGN: This is a single center case series presenting our experience with KTx in aHUS. SETTING AND PARTICIPANTS: This study included 26 patients (16 females) with a diagnosis of aHUS, who spent a median of 5.5 years on kidney replacement therapy before undergoing KTx. We compared the aHUS relapse rate in three groups of patients who underwent KTx: patients who received no prophylaxis, patients who underwent plasma exchange, those who received Eculizumab prophylaxis. Complement factor H-related disease was by far the most frequent etiology (n = 19 patients). RESULTS: Untreated patients and patients undergoing pre-KTx plasma exchange prophylaxis had a relapse rate of 0.81 (CI 0.30-1.76) and 3.1 (CI 0.64-9.16) events per 10 years cumulative observation, respectively, as opposed to 0 events among patients receiving Eculizumab prophylaxis. The time between Eculizumab doses was tailored based on classic complement pathway activity (target to < 30%). Using this strategy, 12 patients are currently receiving  Eculizumab every 28 days, 5 every 24-25 days, and 3 every 21 days. CONCLUSION: Our experience supports the prophylactic use of Eculizumab in patients with a previous history of aHUS undergoing KTx, especially when complement dysregulation is well documented by molecular biology.

Smaller servings vs. information provision: Results of two interventions to reduce plate waste in two university canteens.

Two interventions were systematically evaluated in two university canteens on their effectiveness to reduce visitors' plate waste. The evaluation was theory-based and focused not only at the effects on the amount of plate waste, but also at the psychological predictors underlying plate waste behaviour. In Intervention A, visitors received information about food waste over a period of three weeks. In Intervention B, in addition to information, smaller servings were offered. The actual amount of plate waste and visitors' attitudes, personal norms, beliefs, perceived behavioural control, intentions and plate waste reduction behaviour were measured before and after the interventions. Intervention B reduced the amount of plate waste by 20%, whereas no reduction was found after Intervention A. In both interventions, the provided information resulted in more positive beliefs and stronger personal norms regarding avoiding plate waste. The information also caused attitudes to have a stronger influence on plate waste reduction behaviour, whereas intention to reduce became less important for reducing plate waste. Personal norms regarding food waste were the strongest predictor of plate waste reduction behaviour, before and after the interventions. The provided information was thus insufficient to reduce plate waste, simply offering smaller servings could achieve this. Although our intervention study only included two university canteens and was conducted for a short period, our data seem to imply that a combination of both information and smaller servings reduces plate waste in the food service industry.

Living-Donor Kidney Transplant in a Patient With Type B Mayer-Rokitansky-Küster-Hauser Syndrome, Reconstructed Vagina, and Abnormal Pelvic Vessels: A Case Report.

Mayer-Rokitansky-Küster-Hauser syndrome is a rare disorder consisting of vaginal aplasia and other müllerian duct abnormalities. Urinary tract malfor-mations possibly leading to renal failure are also common. For these patients, kidney transplant remains the best option. However, aberrant anatomy and scarring from previous operations may actually preclude successful implantation of the graft. In this setting, careful pretransplant evaluation with high-resolution imaging studies and multidisciplinary planning are mandatory. We report on a patient with type B Mayer-Rokitansky-Küster-Hauser syndrome, left renal agenesis, right pelvic kidney, grade 3 cystocele, reconstructed vagina, and abnormal vasculature of the pelvis who developed end-stage renal disease due to chronic pyelonephritis. After a thorough preoperative assessment, she eventually underwent simultaneous right pelvic nephrectomy and living-donor kidney transplant. Despite the complexity of the procedure, there were no intraoperative or postoperative complications. After 1 year of follow-up, she is doing well with excellent graft function.

Are there any relations among transplant centre volume, surgical technique and anatomy for donor graft selection? Ten-year multicentric Italian experience on mini-invasive living donor nephrectomy.

BACKGROUND: Selection of the right or left living donor kidney for transplantation is influenced by many variables. In the present multi centric study including 21 Italian transplant centres, we evaluated whether centre volume or surgical technique may influence the selection process. METHODS: Intra- and perioperative donor data, donor kidney function, and recipient and graft survival were collected among 693 mini-invasive living donor nephrectomies performed from 2002 to 2014. Centre volume (LOW, 1-50 cases; HIGH, >50 cases) and surgical technique (FULL-LAP, full laparoscopic and robotic; HA-LAP, hand-assisted laparoscopy; MINI-OPEN, mini-lumbotomy) were correlated with selection of right or left donor kidney and with donor and recipient outcome. RESULTS: HIGH-volume centres retrieved a higher rate of donor right kidneys (29.3% versus 17.6%, P < 0.01) with single artery (83.1% versus 76.4%, P < 0.05) compared with LOW-volume centres. Surgical technique correlated significantly with rate of donor right kidney and presence of multiple arteries: MINI-OPEN (53% and 13%) versus HA-LAP (29% and 22%) versus FULL-LAP (11% and 23%), P < 0.001 and P < 0.05, respectively. All donors had an uneventful outcome; donor bleeding was more frequent in LOW-volume centres (4% versus 0.9%, P < 0.05). CONCLUSIONS: Centre volume and surgical technique influenced donor kidney side selection. Donor nephrectomy in LOW-volume centres was associated with higher risk of donor bleeding.

Environmental Impacts and Hotspots of Food Losses: Value Chain Analysis of Swiss Food Consumption.

Reducing food losses and waste is crucial to making our food system more efficient and sustainable. This is the first paper that quantifies the environmental impacts of food waste by distinguishing the various stages of the food value chain, 33 food categories that represent the whole food basket in Switzerland, and including food waste treatment. Environmental impacts are expressed in terms of climate change and biodiversity impacts due to water and land use. Climate change impacts of food waste are highest for fresh vegetables, due to the large amounts wasted, while the specific impact per kg is largest for beef. Biodiversity impacts are mainly caused by cocoa and coffee (16% of total) and by beef (12%). Food waste at the end of the food value chain (households and food services) causes almost 60% of the total climate impacts of food waste, because of the large quantities lost at this stage and the higher accumulated impacts per kg of product. The net environmental benefits from food waste treatment are only 5-10% of the impacts from production and supply of the wasted food. Thus, avoiding food waste should be a first-line priority, while optimizing the method of treatment is less relevant.

[Surgical overview on kidney and pancreas transplantation]. / Problemi chirurgici nel trapianto di rene e di pancreas - Position paper.

The main purpose of this paper, written by a group of Italian expert transplant surgeons, is to provide clinical support and to help through the decision-making process over pre-transplant surgical procedures in potential kidney recipients, as well as selection of pancreas transplant candidates and perioperative management of kidney recipient. Current topics such as different approaches in minimally invasive donor nephrectomy, methods of graft preservation and treatment of failed allograft were addressed.

Posterior reversible encephalopathy syndrome after kidney transplantation in pediatric recipients: Two cases.

PRES is a neuro-clinical and radiological syndrome that can result as a consequence of several different conditions including hypertension, fluid overload, and immunosuppressive treatment. Herein, we report two children who received kidney and combined liver-kidney transplantation as treatment for renal hypodysplasia associated with bilateral vesico-ureteral reflux and methylmalonic acidemia, respectively. Early after surgery (seven and 10 days), both patients presented with hypertension and seizures. The patients' immunosuppressive regimen included steroid and calcineurin inhibitors (tacrolimus and cyclosporine, respectively) and basiliximab and one with anti-IL2 receptor. In both cases, the imaging strongly supported the diagnosis of PRES. In details, the CT scan showed hypodensities in the posterior areas of the brain, and brain MRI demonstrated parieto-occipital alterations indicative of vasogenic edema. Treatment with calcineurin inhibitors was temporally discontinued and restarted at lower dosage; arterial hypertension was treated with Ca-channel blockers. Both children fully recovered without any neurological sequels. In conclusion, in children undergoing solid organ transplantation, who develop neurological symptoms PRES, should be carefully considered in the differential diagnosis and once the diagnosis is ruled in, we recommend strict arterial blood pressure control and adjustment or withholding of calcineurin inhibitor therapy should be considered based upon blood levels.

Quantifying food losses and the potential for reduction in Switzerland.

A key element in making our food systems more efficient is the reduction of food losses across the entire food value chain. Nevertheless, food losses are often neglected. This paper quantifies food losses in Switzerland at the various stages of the food value chain (agricultural production, postharvest handling and trade, processing, food service industry, retail, and households), identifies hotspots and analyses the reasons for losses. Twenty-two food categories are modelled separately in a mass and energy flow analysis, based on data from 31 companies within the food value chain, and from public institutions, associations, and from the literature. The energy balance shows that 48% of the total calories produced (edible crop yields at harvest time and animal products, including slaughter waste) is lost across the whole food value chain. Half of these losses would be avoidable given appropriate mitigation measures. Most avoidable food losses occur at the household, processing, and agricultural production stage of the food value chain. Households are responsible for almost half of the total avoidable losses (in terms of calorific content).

What has changed in more than 40 years of activity and 3000 kidney transplants at Policlinico University Hospital, Milan.

The activity of kidney transplantation at Policlinico University Hospital, now the Ca' Granda Foundation, was established by Professor Edmondo Malan, who performed the first deceased donor transplantation in Milan, Italy, in 1969. Since then, 2989 kidney transplant procedures (2760 first, 219 second, 10 third transplants) have been performed through the end of November 2011, 2617 of them coming from deceased donors and 372 from living donors. Patient and graft survival have increased since the introduction of cyclosporine and tacrolimus in the last 28 years: 323 living donor-recipients under calcineurin inhibitors (CNI) show patient survival of 95.4% at five years and 88% at 10 years, not significantly different when compared with those of 1968 deceased donor-recipients (93.5% and 86.2%, respectively, at the same time points). Crude graft survival for living donor-recipients under CNI is 84.2% at 5 years and 70.2% at 10 years, not significantly different from those of deceased donor-recipients (80.3% and 64.3% for at the same time points). Actuarial graft survival censored by death is 87.2% at 5 years and 76.5% at 10 years for living donor-recipients vs. 84.4% and 72.2% for deceased donor-recipients, respectively. Previously unacceptable living or deceased kidneys are now successfully transplanted after being repaired with microsurgical techniques at bench. The rate of donors over 60 years of age has increased from 3.8% in the period of 1983-1995 to 20.8% in the last 15 years. It is interesting to note that 306 older kidneys (living donor, deceased donor, first, second, third transplants, with mean donor age of 64.6 +/- 4.0 yrs. and range 60-77 yrs.), always transplanted singularly, have similar behavior if compared with organs coming from donors aging 11-49 years. Survival rates are 93.1%, 90.1%, 88.4%, and 73.2% at 1, 3, 5, and 10 years post-transplant for the older donor grafts vs. 91.2%, 88.1%, 85.4%, and 74.4% for the younger donor grafts at the same time points. Perhaps the practice of dual transplant should be revisited and reserved to very old and ECD-donors. An open subcostal mini-incision (MINI) has been utilized in 177 living donors since 1996. This technique offers the same advantages of hand assisted videolaparoscopic technique, no disadvantages, and no major complications. Although more older and unrelated living donors are included in the MINI-group, very good results are obtained in these recipients, with graft survival censored by death of 97.2%, 95.3%, 93.8%, and 86.3% at 1, 3, 5, and 10 years post-transplant.

Improved treatment feasibility in children with hemophilia using arteriovenous fistulae: the results after seven years of follow-up.

BACKGROUND: An easy and stable venous access is essential in hemophilic children who receive regular prophylaxis or immune tolerance induction treatment. Central venous access devices improve treatment feasibility, but their use is complicated by infection and/or thrombosis. Arteriovenous fistula (AVF) has been evaluated as an alternative to central venous access devices in hemophilic children since 1999. DESIGN AND METHODS: This study provides results obtained in a large series after seven years of follow-up. RESULTS: From 1999 to 2008, 43 procedures were performed in 38 children (median age: 2.7 years). Thirty-five AVFs (81%) achieved maturation after a median of 58 days and were used for a median of five years (range: 0.4-8.5). A brachial artery caliber larger than 1.2 mm was associated with successful maturation (p<0.05). Complications with some impact on arteriovenous fistula use or duration were observed in 14/43 procedures (32%) and in 13/38 children (34%). Age at arteriovenous fistula creation was younger in children who lost arteriovenous fistula patency (p<0.05) and aneurysms were more frequent in children who were on daily treatment regimen and thus had a greater cumulative number of arteriovenous fistula accesses (p<0.05). At the end of the follow-up period, 22 AVFs were still in use and 9 had been surgically dismantled. Arteriovenous fistula use allowed long-term prophylaxis (up to 8.5 years) in 11 children and the completion of immune tolerance induction without interruptions in 18 children. CONCLUSIONS: This study confirms the feasibility of arteriovenous fistula with an acceptable rate of complications and suggests that its use is particularly favorable in children with inhibitors in whom it should be considered as first-choice venous access.

Long-term safety and feasibility of arteriovenous fistulae as vascular accesses in children with haemophilia: a prospective study.

Infectious and thrombotic complications limit the long-term use of subcutaneous ports as venous accesses for children with haemophilia. This study has evaluated for the first time the safety and feasibility of internal arteriovenous fistulae (AVF) as alternative accesses. During the 3-year study period, 27 severe haemophiliacs, 14 with factor VIII inhibitors (52%), underwent the creation of 31 proximal AVF in the forearm. Mild forearm haematomas were observed after five procedures (16%) in five patients who had or developed inhibitors after surgery. Inadequate AVF maturation was observed after five of 31 procedures (16%) in four children. AVF were first accessed after a median of 42 d and regularly used at home by 26 patients (96%) for a median follow-up period of 29 months. Thrombosis of a venous branch occurred in one AVF (3%) after 9 months of uncomplicated use in a child with inhibitor who spontaneously recovered from the symptoms and still used AVF for nine additional months. Mild symptoms, referable to distal ischaemia, were transiently reported by two children (7%) who needed no remedial intervention. This study demonstrates that the use of AVF in haemophiliacs enabled long-term treatment at home in all patients but one.