[Donor and recipient selection in living donor kidney transplantation: eligibility]. / La selezione del donatore e del ricevente nel trapianto di rene da donatore vivente: iter di idoneità.

This review is intended to be a guide for the physician to evaluate and prepare a donor / recipient couple for living kidney transplantation. Although it is intended to be exhaustive, it will not be able to respond at all possible and different cases, but it may apply at most of them. Renal transplantation is considered the choice treatment for patients with chronic renal failure and if the kidney transplant is performed pre-emptive it is associated with better organ and patient survival. The main aim of the program is to evaluate the risks of donor and recipient and to ensure the donor safety and well-being. Eligibility for living transplant can only be granted when the risks are acceptable, well defined and the couple is adequately informed. The review includes clinical and legal procedures needed to transplantation. Early conditions that contraindicate the transplant must be removed, to avoid unnecessary exams, excessive waste of time, money. The sequence of the exams has been ordered so that costly and invasive surveys are carried out only after other simple and essential investigations have confirmed the transplant suitability. Special attention should be paid to the renal function measurement, proteinuria, hematuria, hypertension, obesity, pre diabetes, renal calculus, and cancers. To give eligibility for living transplant is often not easy, but a careful study can avoid many complications and improve the transplant outcome.

Sirolimus vs cyclosporine after induction with basiliximab does not promote regulatory T cell expansion in de novo kidney transplantation: Results from a single-center randomized trial.

Regulatory T cells (Tregs), defined as CD4+CD25+highFoxP3+CD127- cells, could promote tolerance in renal transplantation (Tx). In an open-label, randomized, controlled trial 62 de-novo Tx recipients received induction with basiliximab and cyclosporine A (CsA) for the first month after Tx and then were assigned to treatment with sirolimus (SRL) or CsA and followed up for 2 years. The primary endpoint was to evaluate the effects of induction and maintenance treatments on circulating Tregs, while the secondary endpoint was the assessment of Treg renal infiltration and the relationship between Treg count and clinical outcomes. There were no significant differences in either circulating or tissue Treg number between the two groups. At 1 month post-Tx, all patients presented a profound Treg depletion, followed by a significant increase in Tregs that resulted stable during the follow-up. The same trend was also observed for non-activated Tregs (CD69-) and for other immunocompetent cells (CD4+ and CD8+ T cells, B cells and NK cells). Moreover, the Treg count did not correlate either with renal function or with acute rejection and graft loss. Initial immunosuppression is crucial to regulate circulating Tregs, regardless of subsequent immunosuppressive maintenance regimens. Strategies aiming to promote tolerance should consider the effects of different induction regimens.

[Heparin-induced trombocytopenia: pathogenesis, clinical manifestations and management in hemodialysis]. / Piastrinopenia indotta da eparina: patogenesi, manifestazioni cliniche e management in emodialisi.

Heparin has remained the most commonly used anticoagulant in hemodialysis patients (HD). Its use is usually safe but, in some cases, important adverse effects can occur. Heparin-induced thrombocytopenia (HIT) is an immuno-mediated condition due to the formation of PF4/heparin/IgG complex leading to the activation of platelets and coagulative cascade. The consequent prothrombotic hypercoagulable state may cause venous or arterial thrombosis, skin gangrene and acute platelet activation syndrome. Clinical and laboratory findings may be suggestive for HIT, but formal diagnosis requires the demonstration of the presence of circulating antibodies. Clinical management is complex including the withdrawal of any form of heparin and the administration of anticoagulants. In addition, since anticoagulation is routinely required to prevent clotting of the dialysis lines and membranes, in HD patients presenting HIT it is mandatory to establish heparin-free anticoagulation strategies. Thus, the use of citrate, direct thrombin inhibitors or eparinods have been proposed as alternative anticoagulation approaches in HIT. Here, we review the most important pathogenic factors and clinical features of HIT occurring in HD patients.

Acute kidney injury: effect of hemodialysis membrane on Hgf and recovery of renal function.

OBJECTIVES: Acute kidney injury (AKI) is associated with a high mortality and morbidity rate. In this study we investigated whether dialysis membranes influence the recovery of renal function, through the regulation of hepatocyte growth factor (HGF). DESIGN AND METHODS: 21 patients were enrolled and assigned to hemodialysis (HD) with cellulose (CE, N=11) versus polymethylacrylate (PMMA, N=10) membranes in alternating order. HGF and IL-1 were measured in serum and in peripheral blood mononuclear cells (PBMC) supernatants collected immediately before the first HD session (T0), at 15 minutes (T15), at 240 minutes (T240) and after the last HD, when renal recovery occurred. Eight healthy volunteers were the controls (CON). RESULTS: Time to renal function recovery was lower in CE than in PMMA patients. Serum HGF in HD patients was significantly higher than in CON. HGF levels were higher in CE than in PMMA patients at T15 (13.4±2.7 vs 8.9±3.0 ng/mL, P=0.004) and T240. At recovery, HGF levels decreased. IL-1 serum levels showed a similar trend (at T15 CE: 20.5±2.9 vs PMMA: 16.9±3.2 pg/mL, P=0.005). HGF release significantly increased in the course of HD, resulting in higher levels in CE than that in PMMA patients. Considering all the patients, basal HGF release negatively correlated with time to renal recovery (r2=0.42, P<0.01). CONCLUSIONS: Here we demonstrated that dialysis membranes influence the cytokine profile in AKI patients, HGF release being higher in patients treated with the CE membrane, in comparison to PMMA. Our results suggest that treatment with CE might improve clinical outcomes, possibly through increased release of HGF.