Acute chest syndrome in children with sickle cell disease: Data from a national AIEOP cohort identify priority areas of intervention in a hub-and-spoke system.

Acute chest syndrome (ACS) is a frequent cause of hospitalization in sickle cell disease (SCD). Despite advances in acute care, many settings still lack knowledge about ACS best practices. After the AIEOP Guidelines were published in 2012, suggesting standardized management in Italy, a retrospective study was performed to assess the diagnostic and therapeutic pathways of ACS in children. From 2013 to 2018, 208 ACS episodes were presented by 122/583 kids in 11 centres. 73 were male, mean age 10.9 years, 85% African, 92% HbSS or Sß°. In our hub-and-spoke system, a good adherence to Guidelines was documented, but discrepancies between reference centres and general hospitals were noted. Improvement is needed for timely transfer to reference centres, use of incentive spirometry, oxygen therapy and pain management.

Influence of individual or group housing of newborn calves on rotavirus and coronavirus infection during the first 2 months of life.

Bovine rotavirus A (RVA) and bovine coronavirus (CoV) are the two main viral enteropathogens associated with neonatal calf diarrhea. The aim of the present work was to study the impact of group and individual housing systems in the epidemiology of RVA and CoV infection. Eleven calves reared in individual housing (FA) and nine calves in group housing (FB) were monitored during the first 7 weeks of life. Stool and serum samples were screened for RVA and CoV antigens by ELISA. IgG1 antibodies (Ab) to both antigens were also measured. From the 160 fecal samples collected, the proportion of positive samples to RVA and CoV was significantly higher in FB (23.6%) than in FA (9%) (p = 0.03). The geometric mean of colostral IgG1 Ab titers to CoV and RVA in FA (IgG1 anti-CoV 1024 and anti-RVA 1782.9) was lower than in FB (IgG1 anti-CoV 10,321.2 and anti-RVA 4096) at birth. Calves less than 2 weeks of life from FB had a higher risk of being infected by RVA (OR = 4.9; p = 0.01) and CoV (OR = 17.15; p = 0.01) than calves from FA. The obtained results showed that there was higher RVA and CoV shedding in group-housed calves than in individual-housed animals.

First report of group A rotavirus and bovine coronavirus associated with neonatal calf diarrhea in the northwest of Argentina.

Group A rotavirus (RVA) and bovine coronavirus (BCoV) are the two main viral enteropathogens associated with neonatal calf diarrhea. The aim of the present survey was to investigate the epidemiology and the role of RVA and BCoV in the presentation of dairy and beef calf diarrhea in Lerma Valley of Salta province, within the Northwest region of Argentina. Stool samples of calves with or without diarrhea younger than 2 months of age were collected from 19 dairy farms and 20 beef farms between the years 2014 and 2016. Stool samples were screened for RVA and BCoV detection by ELISA. Heminested multiplex RT-PCR was used for RVA typing and RT-PCR to confirm BCoV. Positive samples were submitted to sequencing analysis. Bovine RVA and BCoV were circulating in 63% (12/19) and 10.52% (2/19) of the dairy farms, respectively, where 9.5% (46/484) of the calves were positives to RVA and 0.4% (2/484) to BCoV. In beef herds, RVA was detected in 40% (8/20) of the farms and in 6.75% (21/311) of the calves, without positives cases of BCoV. Molecular analysis showed that in dairy farms, G6P[11] and G10P[11] were the prevalent RVA strains, while in beef farms, G10P[11] was the prevalent. The main finding was the detection for the first time of a G15P[11] causing diarrhea in beef calves of Argentina that represents a new alert to be consider for future vaccine updates. Analysis of detected BCoV showed that it is related to the other circulating strains of Argentina.

Descripción de dos casos de babesiosis cerebral en terneros de hasta 15 días de edad / Description of two cases of cerebral babesiosis in calves up to 15 days of age

Resumen La babesiosis es una enfermedad causada por Babesia bovis y Babesia bigemina, integrante del complejo conocido como "Tristeza bovina" y relevante en el Noroeste argentino (NOA). La presentación clínica de esta enfermedad es infrecuente en bovinos jóvenes, a los que se considera parcialmente resistentes a la babesiosis. Este trabajo describe dos casos de babesiosis cerebral en terneros de dos rodeos de cría diferentes, que a la necropsia mostraron ictericia, esplenomegalia y severa congestión cerebral y hemoglobinuria. Estructuras intraeritrocitarias compatibles morfológicamente con B. bovis fueron identificadas en extendidos de sistema nervioso central y sangre periférica teñidos con Giemsa y se confirmó luego la infección por medio de técnicas moleculares. La evaluación del estatus epidemiológico en los rodeos de origen determinó diferentes contextos: uno de los casos fue aislado en un rodeo con estabilidad enzoótica para babesiosis, donde la enfermedad clínica era escasa a pesar de altas tasas de transmisión de B. bovis; el segundo caso ocurrió en un rodeo en situación de brote con niveles significativos de mortandad. La ocurrencia de babesiosis (B. bovis) no había sido descripta todavía en terneros de la Argentina, sumándose ahora al diagnóstico diferencial para esta categoría de bovinos en zonas donde la enfermedad es enzoótica.

Abstract Bovine babesiosis is a disease caused by Babesia bovis and Babesia bigemina, as part of the tick fever complex and relevant in the Northwest of Argentina. Clinical occurrence of this illness is uncommon in young cattle, considered resistant to babesiosis. This work described two cases of cerebral babesiosis in calves of different beef herds. Jaundice, splenomegaly, severe cerebral congestion and hemoglobinuria was observed at necropsy. Babesia bovis-like structures were identified in cerebral and blood smears Giemsa stained and confirmed by molecular techniques. Different situations were recognized following the evaluation of the epidemiological status of both herds: the first one was a single case in a herd with enzootic stability for babesiosis, with scarce clinical cases despite high rates of B. bovis transmission; the other case was in a context of outbreak with high level of mortality within a herd susceptible to babesiosis. Clinical babesiosis was not previously described in calves from Argentina. Babesiosis must be taken into account for the differential diagnosis in calves from endemic areas of the disease.

Conversion from calcineurin inhibitors to everolimus with low-dose cyclosporine in renal transplant recipients with squamous cell carcinoma of the skin.

Squamous cell carcinoma of the skin (SCC) is the most frequent cancer in renal transplant recipients. Conversion to mammalian target of rapamycin inhibitors after diagnosis of SCC may reduce the incidence of recurrence of skin cancer. This retrospective study evaluated the outcome of renal transplant recipients followed by the Renal Unit with posttransplant diagnosis of SCC treated with conversion from calcineurin inhibitors (CNIs) to Everolimus (EVR) associated with low-dose cyclosporine. Eleven patients developed SCC at a median time from renal transplantation of 107 months (range 36-264). Five patients with creatinine clearance (CCl) below 40 mL/min before conversion developed end stage renal disease (two cases) or further deterioration of renal function (two cases); only one patient in this group maintained a stable renal function. The remaining six patients with a CC1 greater than 40 mL/min and proteinuria below 0.8 g/24 hours maintained a stable renal function after conversion to EVR at a median follow-up of 22 months (range 15-75). Conversion from CNIs to EVR has been proven safe, effective, and associated with low recurrence of SCC in patients with a CCl >40 mL/min. In the case of preexisting deterioration of renal function or significant proteinuria, conversion to EVR should be carefully evaluated.

Contrast-enhanced ultrasound assessment of complex cystic lesions in renal transplant recipients with acquired cystic kidney disease: preliminary experience.

We prospectively studied the potential value of contrast-enhanced ultrasound (CEUS) to characterize complex acquired cystic kidney disease (ACKD) or suspected solid renal masses, avoiding the risk of inducing acute kidney injury in 138 renal transplant recipients by contrast-enhanced computed tomography (CT). Forty-three cases (31%) had ACKD; 15 ACKD patients (35%) showed suspicious or nondiagnostic ultrasound. The latter subgroup underwent CEUS and, if the suspicion was confirmed, a contrast-enhanced CT. Thirty five lesions were identified in the 15 patients studied by CEUS. According to the Bosniak classification, 27 cysts were type I (BI), four type II (BII), two type III (BIII) with enhancement at the level of thickened septa; we also identified two solid enhancing lesions (BIV). We followed the BI and BII lesions with serial CEUS, while the remaining four cases underwent contrast-enhanced CT showing two solid lesions and two complex cysts with contrast enhancement in the septea. The four patients underwent surgical resection yielding three renal cell carcinomas one papillary carcinoma as the pathological findings. This preliminary study characterized solid nodules and BIII lesions for further evaluation by CT. CEUS seems to correctly characterize BI and BII cysts that are not clearly defined by standard ultrasound.

Renin angiotensin system blockade and activated vitamin D as a means of preventing deep vein thrombosis in renal transplant recipients.

BACKGROUND: Venous thromboembolism (VTE) is one of the thrombotic complications that occur in renal transplant recipients (RTR). The observation that vitamin D receptor activators, angiotensin-converting enzyme inhibitors (ACEi), and angiotensin receptor blockers (ARBs) have a protective effect against protrombotic state suggests that their possible combination could reduce the incidence of VTE in RTR. OBJECTIVES: to evaluate the incidence of VTE in RTR and the timing of occurrence after renal transplantation (Tx); to compare the incidence of VTE in our RTR and RTR on calcitriol, ACEi, ARBs and their combination therapy. Risk factors were also evaluated. RESULTS: During follow-up, 96 of 769 RTRs, 73 males 23 females, developed a first episode of VTE: 23 in the first 3 months after Tx; 15 from 3 to 6 months; 9 from 6 to 12 months; 13 from 12 to 48 months and 36 after more than 48 months. The incidence was significantly lower in RTR on treatment with a combination of calcitriol 0.25 µg/day, an ACEi and an ARB and in RTR on treatment with only calcitriol 0.5 µg/day (9.4% and 9%, respectively, vs. 14.5% (p < 0.05)). However, the most decreased rate (5.6% vs. 14.5% (p < 0.01)) was in patients treated with a combination of calcitriol 0.5 µg/day, an ACEi and an ARB. CONCLUSION: A combination therapy with calcitriol 0.5 µg/day, ACEi, and ARB is associated with a 60% lower rate risk of VTE.

Donors positive for hepatitis B core antibodies in nonliver transplantations.

We reviewed available, particularly epidemiological data regarding transplantation of organs from donors positive for hepatitis B core antibodies (HBcAb) to evaluate the possibility of transmitting the disease. For nonhepatic organs, the risk is low: higher for lung but lower for kidneys and heart, according to the quantity of lymphoid tissue. The use of such organs is increasing owing to the worldwide organ shortage. Unfortunately, even if the use of HBcAb-positive donors does not seem to affect patient or graft survival, the United Network for Organ Sharing and United States Renal Data System registries do not have data on hepatitis B incidence after transplantation. Cohort data suggest that the use of such donors is safe if one follows suggested guidelines. In particular, recipients with no evidence of HBsAb should receive prophylaxis with either lamivudine or HB immunoglobulin. Our data show a 15%-20% incidence of HBcAb-positive donors, as in other European countries. The 1-year graft outcomes are good, with a 3% seroconversion rate to HB surface antigen.

Kidney graft survival rates do not improve by era: the impact of the age factor.

We performed this study to evaluate whether older ages of donors and recipients negatively affected long-term graft survival. We compared 5-year graft survival rates of 89 recipients transplanted between 1991 and 1995 (period A) versus 221 recipients transplanted between 1996 and 2000 (period B). Acute rejection rates and the number of donors and recipients >50 years of age were compared in the two periods. The 5-year graft survival rate in period B was 76.3% versus 82% in period A. In period B, the acute rejection incidence was 18% versus 40% in period A (P < .001). The overall 5-year graft survival was 86.2% for donors aged 21-50 years and 65.7% for donor's aged >50 years (P < .0001) in period A versus 84.1% and 68%, respectively, in period B (P = .0023). In period A, 23.6% of donors and 35.9% of recipients were >50 years old, versus 50.2% and 42.9%, respectively, in period B. The graft survival rate in period B was worse than in period A, although the acute rejection rate was lower. The older age of both donors and recipients in period B seemed to be an important cause of worse outcomes.

Subcutaneous nodules and infectious complications in renal allograft recipients.

Renal transplant recipients are at increased risk of infectious diseases and subject to cutaneous infections because of the effects of immunosuppressive therapy. Some long-term descriptive follow-up studies confirm that skin infections are common among renal transplant recipients. We report the development of subcutaneous nodules among patients receiving renal transplantations from 1991 to 2009. Transplant recipients were followed by the Nephrology Unit at control visits according to the American Society Nephrology guidelines. Between 1991 to 2009, subcutaneous nodules were identified in 7 out of 774 renal transplant recipients. The male:female ratio was 5:2; median age at renal transplantation was 52 years (range 28-59). Subcutaneous nodules were identified at a median 3 years after transplantation. The 7 patients had the following diagnoses: systemic scedosporiasis (n = 1); Mycobacterium avium complex infection (n = 2) disseminated tuberculosis (n = 2) Sporothrix schenckii infection (n = 1); Trichophyton rubrum infection (n = 1). Four patients died due to sepsis from disseminated infection. Subcutaneous nodules may reflect a systemic infectious pathology. In some cases, the investigation of cutaneous lesions is important to reach a definitive diagnosis for possible future disseminated infections.

Reticulated platelets and platelet reactivity in renal transplant recipients receiving antiplatelet therapy.

INTRODUCTION: Renal transplant recipients are at increased risk of cardiovascular morbidity and mortality. We assessed platelet reactivity and reticulated platelets (RPs) in 90 recipients, 51 (56.6%) of whom were not receiving acetylsalicylic acid (ASA) therapy (group A) and 39 (43.3%) who were receiving ASA therapy, 100 mg (group B), and in 60 healthy controls (group C). METHODS: Reticulated platelets were measured using a hematology automated analyzer (XE-2100; Sysmex Corp, Kobe, Japan) and were expressed as the percentage of RPs in the total optical platelet count (immature platelet fraction [IPF]), as the percentage of highly fluorescent RPs, and as the absolute number of RPs (IPF#). Platelet function was assessed using optical aggregometry (platelet aggregation) induced using 1 mmol/L of arachidonic acid, 2 or 10 micromol/L of adenosine diphosphate, or 2 microg/mL of collagen. RESULTS: Group A demonstrated significantly higher values of RP compared with group B or group C. Group B demonstrated a substantially higher percentage of RPs compared with group C, which was significant only for the IPF parameter. Multiple regression analysis demonstrated that IPF and IPF# were significantly and positively related to collagen-induced platelet aggregation. CONCLUSION: We documented the presence of higher concentrations of RPs in transplant recipients compared with a control population, and a significant association between RPs and platelet function.

Superior efficacy of enteric-coated mycophenolate vs mycophenolate mofetil in de novo transplant recipients: pooled analysis.

Dose reduction and discontinuation of mycophenolate mofetil (MMF) therapy because of gastrointestinal complications has been associated with increased risk of acute rejection episodes and graft loss. Enteric-coated mycophenolate sodium (EC-MPS) delays release of mycophenolic acid (MPA), and was designed to reduce MPA-related gastrointestinal adverse events. Data comparing the efficacy of EC-MPS vs MMF in de novo renal transplant (RTx) recipients from large prospective studies are limited. Therefore, a pooled data analysis was performed based on 1891 de novo RTx recipients receiving EC-MPS (n = 1289) or MMF (n = 602) plus cyclosporine and steroid therapy in 4 prospective multicenter studies with similar entry criteria. In all trials, the initial dose of EC-MPS was 1440 mg/d, and of MMF was 2000 mg/d; both dosages deliver equimolar amounts of MPA. Induction therapy was permitted in 2 studies per center practice. Multivariate logistic regression analysis was performed, adjusting other potential explanatory variables including recipient age, sex, and race/ethnicity; induction therapy; and diabetes mellitus at baseline. In addition, propensity scores were used to explain potential bias. Mean (SD) MPA dose (EC-MPS dosage was converted to MMF equivalent) during months 0 to 12 was similar: EC-MPS, 1820 (370) mg/d, vs MMF, 1860 (290) mg/d. However, at univariate and multivariate analyses, the rates of treatment failure, biopsy-proved acute rejection episodes, and graft loss were significantly lower with EC-MPS compared with MMF at month 12. In conclusion, this pooled analysis documents a substantial improvement in efficacy in de novo RTx recipients receiving EC-MPS vs MMF with concomitant cyclosporine and steroid therapy.

Lower homocysteine levels in renal transplant recipients treated with everolimus: a possible link with a decreased cardiovascular risk?

Cardiovascular disease (CVD) is the main cause of morbidity and mortality in renal transplant recipients. The incidence of CVD in this setting is approximately 5-fold greater than in age- and and gender-matched subjects. This excess cardiovascular risk is not completely explained by traditional cardiac risk factors. It has been well documented that these patients show greatly increased prevalence of both fasting and postmethionine-loading hyperhomocysteinemia (hHcy) compared with the general population. An immunosuppressive therapy based on everolimus has been demonstrated to reduce the incidence major adverse coronary events at 4 years compared with azathioprine among heart transplant recipients. In contrast, scarce data are available on the impact of everolimus on emerging risk factors, such as homocysteine (Hcy), in renal transplant recipients. The aim of this study was to evaluate the possible impact of everolimus compared with other immunosuppressive regimes among 132 stable recipients, including 91 men and 41 women who were at least 1 year after transplant with stable renal function and no clinical evidence of acute or chronic renal graft rejections. We compared 31 subjects on everolimus immunosuppressive therapy (group A) versus 101 on immunosuppressive therapy based on cyclosporine, steroids, and mycophenolate. The Hcy levels were significantly lower among group A patients compared with group B: 16.5 +/- 5 micromol/L vs 21.2 +/- 11 micromol/L; P < .005. Hyper-Hcy, defined as Hcy levels >15 micromol/L, was diagnosed in 18 out of 31 patients (51%) of group A and in 82 out of 101 patients (81%) of group B. This preliminary study demonstrates a favorable impact of everolimus on a marker of atherothrombosis which is associated with a worse vascular prognosis.

Blood rheology and renal transplantation: an intriguing relationship for assessing cardiovascular risk.

Renal transplant recipients (RTRs) are at increased risk of cardiovascular complications. An altered hemorheological profile may determine both cardiovascular complications and progression of renal failure in RTRs. We performed this study to evaluate the rheologic status in 239 RTRs at least 12 months after transplantation with stable and normal renal function compared with 90 control subjects. In RTRs, a significantly higher hematocrit-adjusted, but not native, whole blood viscosity was found (P < .0001). Moreover, plasma viscosity and red blood cell deformability were significantly higher in patients than in control subjects (P < .0001), whereas no difference in erythrocyte aggregation between patients and control subjects was observed (P = .5). Fibrinogen, but not hematocrit, significantly increased in RTRs (P = .001). This preliminary study provides evidence of an altered hemorheologic profile in RTRs.

Keratinocyte cancer prevention with ACE inhibitors, angiotensin receptor blockers or their combination in renal transplant recipients.

BACKGROUND: Skin cancer (SC) is the most frequent malignancy after renal transplantation (RT), especially squamous and basal cell carcinoma. The observation that angiotensin II is a potent angiogenic and growth factor raises the possibility that blocking its effects could reduce the incidence of skin cancer. OBJECTIVES: To evaluate the incidence of keratinocyte cancer in RT recipients, the timing of occurrence of the skin events after RT; to compare the incidence of SC in our RT recipients and in RT patients on angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers therapy (ARBs) and their combination. Risk factors were also evaluated. RESULTS: During follow up, 52 of 565 patients (9.2%), 38 males 14 females, developed SC at a median time of 59 months (range 29 - 74) after RT. 12 of 52 patients (23%) with SC were on ACEi, ARBs therapy or their combination. The incidence was significantly lower in user patients compared to non user (5.6% and 11.4% respectively). BCC was the most frequent type of keratinocyte cancer in non users and in users. No association with incidence of BCC or SCC was observed for other classes of antihypertensive drugs (calcium antagonists, beta-blockers, alpha-blockers). CONCLUSION: This study confirms that RT patients are at high risk of SC. The use of ACEi or ARBs is associated with an approximately two-fold reduced risk of Keratinocyte cancers compared to non users in RT recipients. We did not observe an association between the incidence of SC and the use of other classes of antihypertensive drugs. Any chemoprotective effect of these agents may reflect inhibition of the growth factor activity of angiotensin II. Use of ACEi or ARBs, when this is possible, should be considered in RT patients with multiple risk factors.

Preemptive cadaveric renal transplantation: fairness and utility in the case of high donation rate-pilot experience of Tuscany region.

Preemptive kidney transplantation is performed before the initiation of chronic dialysis. Preemptive transplantation is the best treatment modality for patients reaching end-stage renal disease. The Tuscany region has experienced, in the last years, a marked increase in donation rate. Starting from 2006, the first Italian cadaveric preemptive transplant program was activated. The aim of our study was to investigate the characteristics and preliminary results of this program. Among 163 patients entered on to the waiting list for renal transplantation from October 2006 to October 2008, 120 (73.6%) were on dialysis for 21.3 +/- 17.8 months, whereas 43 patients (26.4%) had not yet been on dialysis (preemptive). Eighty two patients (50.3%) resided in Tuscany and 81 (49.7) outside Tuscany; 36.6% of Tuscany patients and 16% of extraregional patients (P = .003) were listed as preemptive. Fifty-eight of 163 (35.6%) patients were transplanted during the period after a mean waiting time of 10.3 +/- 6.4 months. The estimated overall man waiting time was 17.5 months (confidence interval (CI) = 15.8-19.2). Upon Cox multivariate analysis, the probability of transplantation was similar for preemptive and dialysed patients (relative risk [RR] 1.02, P = NS). According to local allocation policy, only residents of Tuscany showed a significant advantage in both groups (RR = 0.43, CI = 0.24-0.75, P = .003). Two-year graft and patients survivals were similar, but delayed graft function was lower in the preemptive group (13% vs 42%, P = .007). The 1-year serum creatinine was 1.56 +/- 0.43 in the preemptive group and 1.68 +/- 0.92 in the dialysis group (P = NS). No differences were observed concerning rejection rate. The preemptive listing rate for cadaveric renal transplantation was more than 35% for Tuscany patients.

Preemptive therapy for the prevention of cytomegalovirus disease in renal transplant recipients: our preliminary experience.

BACKGROUND: Cytomegalovirus (CMV) disease represents an important cause of morbidity in renal transplant recipients. We report our preliminary evaluation of the efficacy and security of preemptive therapy to manage renal transplant recipients with evidence of active CMV replication. METHODS: Preemptive therapy with gancyclovir and/or valgancyclovir (VGCV) was recently substituted for CMV antiviral prophylaxis at our institution. Between May 2006 and December 2007, all patients undergoing renal transplantation were included in a CMV infection surveillance program. Blood samples to determine CMV viral load were obtained weekly during the first 4 months. Asymptomatic patients, with a viral load determined using polymerase chain reaction (PCR) with CMV DNA >100,000 copies/mL, were treated with VGCV for 3 months or until resolution of viral replication. Until April 2006, patients undergoing renal transplantation received CMV prophylaxis with oral acyclovir and pp65 antigenemia was the test for CMV infection surveillance. The group on preemptive therapy was compared with a historical group on prophylaxis therapy: 100 renal patients who underwent transplantation between April 2004 and 2006. RESULTS: Among 96 recipients, quantitative determination of viral DNA in blood was elevated in 14 asymptomatic patients, who were treated with oral VGCV for 3 months. The patients were followed up for a median time of 13.3 months. None of the 14 patients who received VGCV developed CMV disease. CONCLUSION: VGCV administered as preemptive therapy was safe and efficacious to prevent CMV disease.

Posttransplant proteinuria associated with everolimus.

Anti-mTOR may induce proteinuria when utilized after renal transplantation. Little is known about the pathogenesis and composition of proteinuria. To clarify this unresolved aspect, we analyzed urinary protein composition utilizing an integrated proteomics approach, including quantitative assays, 2-dimensional electrophoresis, MALDI-TOF, and Western blots among 48 renal transplant recipients treated with everolimus (EVL; n = 31) or enteric-coated mycophenolic acid (EC-MPA; n = 17). High (>3 g/d) or intermediate levels of proteinuria (1-3 g) developed in 12 EVL patients (39%) compared with 4 subjects (23%) in the EC-MPA group. Proteinuria, which started during the first 2 days after EVL, tended to reduce during the follow-up. Quantitative proteomics showed an increase in low molecular proteins beta2 microglobulin (P < .001) and alpha1 microglobulin (P < .025). Qualitative proteomics showed a marked increase among all urinary components in EVL and EC-MPA patients. Major changes involved typical components of glomerular damage: albumin, Zn-alpha1 glycoprotein, alpha2HS glycoprotein, and leucine-rich alpha2 glycoprotein. In addition, we observed specific biomarkers for EVL: clusters of alpha1-antitrypsin fragments and monoclonal lambda chains. In conclusion, EVL induced proteinuria of a mixed glomerular and tubular origin that correlated with the start of treatment and reached nephrotic ranges in few cases. The specific urinary markers may reflect renal alterations related to the transplant or specific alterations associated with the drug.

Disseminated Scedosporium apiospermum infection in renal transplant recipient: long-term successful treatment with voriconazole: a case report.

Scedosporium apiospermum, the asexual form of Pseudallescheria boydii, is a ubiquitous fungus that represents an unfrequent complication of immune suppression. It accounts for 20% of all non-Aspergillus mold infections in organ transplant recipients. The infection can be localized or disseminated in multiple organs, including lungs, brain, joints, tendons, and skin, and is difficult to treat, due to resistance of S apiospermum to amphotericin B and other antifungal agents. The mortality rate is about 50%. To our knowledge, there are no prospective studies or registries of transplant recipients to guide diagnosis and there are no evidence-based recommendations for the optimal management of this infection. We report a case of S apiospermum infection in a woman with renal transplantation. The first occurrence of infection was a solitary nodule on the forearm, which was surgically excised. Two following relapses were disseminated to the knee, the Achilles tendon, and the skin of the left leg. The infection was successfully treated with voriconazole, but due to the severe iatrogenic immune suppression, a strong reduction in immunosuppressant drugs was needed.

[Kidney transplant failure and retransplantation.]. / Fallimento di trapianto renale, rientro in dialisi e retrapianto.

Transplant failure is a more and more frequent cause of end stage renal failure and dialysis. Patient survival rate after graft failure is very varied according to different reports. Better survival is mainly a consequence of good continuum of care thanks to improved interaction between dialysis and transplant center. Diabetic and elderly patients, as well as patients affected by cardiovascular disease are the subjects at higher risk: if judged clinically adequate to enter the waiting list, they should be retransplanted as soon as possible. Dialysis survival of patients with failed kidney transplant is strictly linked to adequate dialysis dose. Second transplant survival rate is higher in the case of a living donor and if the first transplant survived longer. Good immunologic match is also a condition linked to higher graft and patient survival rate. High body mass index, smoking and severe cardiovascular comorbidity should be avoided. Whether to keep low immunosuppression levels after first graft failure and whether to excise the failed kidney, even though it shows no clinical problems, are issues still under debate. Low-dose immunosuppression is not recommended since it may result in higher rate of infectious and neoplastic diseases. The failed kidney should be removed not only in the case of clinical disease, but also when the retained failed kidney is associated with chronic inflammation, as shown by high C-reactive protein levels and erythropoietin resistance.