Towards a sustainable fisher-dolphin coexistence: Understanding depredation, assessing economic damage and evaluating management options.

Finding solutions for a sustainable coexistence between wildlife and humans is considered among the most challenging environmental management issues for scientists, conservationists, managers, and stockholders world-wide. Depredation by the common bottlenose dolphin (Tursiops truncatus) on small scale fisheries has increased in the recent years, leading to a growing conflict in many areas of the Mediterranean Sea and pressing for urgent management solutions. This study aims at developing a management framework for a sustainable coexistence between fishers and dolphins in Sardinia (Mediterranean Sea). Relying on the combination of different approaches (field study, literature review and Multi Criteria Decision Analysis), the scientific evidence necessary for understanding dolphin depredation were updated and improved, the related economic damage was calculated, and different management options were identified and evaluated by several stakeholder groups to support the decision-making process. Averaging for all investigated net types (gillnet and trammel net), a depredation frequency of 53% was found, the highest values ever found in both Sardinia and many other Mediterranean sites. Depredation probability was influenced by different factors, such as net type, fishing operation duration, depth of the fishing site and period. The estimated economic damage due to depredation ranges on average between 6492 and 11,925 euro per year and depends on the type of fishing net. The results from the field study, the literature review and the stakeholder involvement allowed us to define the most plausible and shared management options, identifying a framework for assessing and managing the conflict between fishers and dolphins for the creation of a more sustainable vision for the future.

Medullary sponge kidney: unusual finding in kidney transplant recipient.

BACKGROUND: Medullary sponge kidney is generally considered a benign condition, gold standard for the diagnosis is urography but it has almost been replaced by UroCT that did not present the same sensibility. Although it is really rare, our sonography's findings were consistent with medullary sponge kidney in the transplanted kidneys. CASE PRESENTATION: A 45-year-old woman with a long history of double-kidney transplantation complained of frequent urinary tract infections, a history of vague loin pain and came to our attention for sonography follow-up. Her kidney function was normal, we did not find signs of infections in the transplanted kidneys and urinary findings were normal. Curiously, the transplanted kidneys came from a newborn and the patient received a double-kidney transplantation in order to guarantee a satisfactory renal function. CONCLUSIONS: Despite a long history of kidney transplantation, genetic disease should not be forgotten when symptoms and images recall to specific inherited alterations. Sonography has to be considered in diagnostic path of kidney cystic disease.

MR Brain Screening in ADPKD Patients : To Screen or not to Screen?

BACKGROUND: Adult polycystic kidney disease (ADPKD) still represents a major cause of renal failure and intracranial aneurisms (IA) have a higher prevalence in ADPKD than in the general population. Current guidelines suggest performing brain MRI only in the subjects with a positive familiar history of IAs or subarachnoid hemorrhage (SAH). This is a retrospective case-control analysis to evaluate the usefulness of a MR screening program in ADPKD patients. METHODS: We retrospectively analyzed all ADPKD patients followed in our outpatient clinic between 2016 and 2019 who underwent a brain MRI screening. We evaluated the presence of IAs and others brain abnormalities and compared our results with a non-ADPKD population (n = 300). We performed univariate and multivariate regression analysis to evaluate if general and demographic features, laboratory findings, clinical parameters and genetic test results correlated with IAs or other brain abnormalities presence. RESULTS: Among the patients evaluated 17 out of 156 (13.6%) ADPKD patients had IAs, compared to 16 out of 300 (5.3%) non-ADPKD controls (p < 0.005). Considering ADPKD patients presenting IAs, 12 (70.6%) had no family history for IAs or SAH. Genetic analysis was available for 97 patients: in the sub-population with IAs, 13 (76.5%) presented a PKD1 mutation and none a PKD2 mutation. We found that arachnoid cysts (AC) (p < 0.001) and arterial anatomical variants (p < 0.04) were significantly more frequent in ADPKD patients. CONCLUSION: In our population ADPKD patients showed a higher prevalence of IAs, AC and arterial variants compared to non-ADPKD. Most of the IAs were found in patients presenting a PKD1 mutation. We found a significant number of alterations even in those patients without a family history of IAs or SAH. The practice of submitting only patients with familial IAs or kidney transplantation candidates to MRI scan should be re-evaluated.

Variations in coralligenous assemblages from local to biogeographic spatial scale.

The present study aims at contributing to the knowledge of the spatial variability of coralligenous reefs through the evaluation of patterns ranging from local to biogeographic scale around the island of Sardinia. The coralligenous reef assemblages of six areas were studied through a hierarchical sampling design: three sites per area were selected, in each site three plots were sampled and in each plot ten photographic samples were collected. The structure of coralligenous reefs across closed biogeographic regions is described, highlighting that nearly pristine assemblages, although characterized by similar high diversity, can be either dominated by animals, such as gorgonians and bryozoans, or macroalgae. The observed variations seem largely related to biogeographic patterns rather than spatial distance, supporting the need to identify specific reference conditions to assess the ecological quality of this habitat depending on the biogeographic area to be monitored.

Evolution of the concept of quality of life in the population in end stage renal disease. A systematic review of the literature.

BACKGROUND AND AIMS: Given the rising prevalence of end-stage renal disease and subsequent progressive increase of patients starting renal replacement therapy, a great attention is given by scientific community to the assessment of life perception and Quality of Life (QoL) in dialysis patients. A broad literature review was conducted on PubMed and PsyInfo databases for articles published between January 2000 and July 2016 in order to understand the biological and psychosocial variables potentially affecting the QoL of the patients under artificial substitution of kidney function. METHODS: Five domains related to the concepts of physical functions, mood, sleep, spirituality, and social support have been identified. RESULTS: The findings in this review suggest that the variables related to physical activity and depression seem to have a direct impact on QoL and Health-Related Quality of Life (HRQoL). Others, such as anxiety, awareness, empowerment, the presence of sleep disorders, satisfaction, support from the staff, social support, spirituality and religion have a clear correlation with the QoL dimensions. CONCLUSIONS: These results suggest the primary importance of the assessment biological and psychosocial variables by specific tools and the inclusion of effective interventions targeted to patients and their caregivers.

Neoplasms and renal transplantation: impact of gender, comorbidity and age on in-hospital mortality. A retrospective study in the region Emilia-Romagna of Italy.

OBJECTIVE: The aim of this retrospective study was to investigate the relationship between cancer, non-immunologic comorbidity, estimated by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codification, gender and in-hospital mortality (IHM) in a large sample of renal transplant recipients (RTRs) living in the region Emilia-Romagna (RER) of Italy. PATIENTS AND METHODS: We evaluated IHM in RTRs admitted between 2000 and 2013 recorded in the RER database. By using ICD-9-CM codes, the Elixhauser index (EI) was calculated, and cancers were identified and classified as skin cancers (SC), solid organ cancers (SOC) and post-transplant lymphoproliferative disorders (PTLD). IHM was the dependent variable of the multivariate models, while age, gender, EI corrected removing the effect of malignancies (cEI), and different types of cancer were the independent ones. RESULTS: During the examined period, a total of 9,063 admissions in 3,648 RTRs were recorded, of whom 117 died (3.2%). The mean age was 52.9±13.1 years. Cancers were reported in 580 admissions (6.4%), and mean cEI was 3.5±3.4. Deceased RTRs were older, had a higher prevalence of PTLD and SOC, and had a higher cEI than survivors. IHM was independently associated with (in decreasing order) PTLD (OR 12.431, 95%CI 5.834-26.489, p<0.001), SOC (OR 6.804, 95%CI 4.323-10.707, p<0.001), female gender (OR 1.633, 95%CI 1.057-2.523, p=0.006), cEI (OR 1.106, 95%CI 1.068-1.145, p<0.001), and age (OR 1.049, 95%CI 1.031-1.068, p<0.001) CONCLUSIONS: Cancer, in particular SOC and PTLD, is strongly associated with IHM in RTRs. On the other hand, rather surprisingly, female gender exhibited a stronger association with IHM than other more expected factors, such as comorbidity and age.

Correlation Between Renal Cortical Stiffness and Histological Determinants by Point Shear-Wave Elastography in Patients With Kidney Transplantation.

INTRODUCTION: Renal allograft biopsy is the gold standard for the detection of histological lesions of chronic allograft dysfunction. The identification of a noninvasive routine test would be desirable. Elastosonography is used to assess tissue stiffness according to viscosity, and no data are available on the use of point quantification shear-wave elastography (ElastPQ) for the evaluation of renal chronic lesions. RESEARCH QUESTION: To evaluate the feasibility of ElastPQ to assess cortical allograft stiffness and to determine the correlation of clinical, biological, and pathological factors with the diagnostic accuracy of kidney stiffness values in patients with histological lesions. DESIGN: Forty-two patients underwent kidney transplant biopsy and 10 valid measurements of ElastPQ, blindly performed by 2 operators. The interobserver reproducibility was assessed according to intraclass correlation coefficient. The ElastPQ measurements and the clinical data were compared using the Spearman correlation analysis. RESULTS: 97.6% reliable measurements were obtained using ElastPQ, with an excellent interobserver agreement. The kidney stiffness was significantly higher in the patients with a time since transplantation >12 months and was correlated with chronic lesions (interstitial fibrosis, tubular atrophy transplant glomerulopathy, and mesangial matrix), with the interstitial fibrosis/tubular atrophy, score and with the sum of the scores of the chronic lesions. Mesangial matrix increase is the only independent determinant of kidney stiffness. DISCUSSION: ElastPQ is a noninvasive, reproducible, and sensitive diagnostic tool able to detect moderate/severe chronic lesions. Its routine use during follow-up can identify patients eligible for biopsy, which remains the gold standard exam for detecting chronic allograft dysfunction.

Body mass index and metabolic syndrome impact differently on major clinical events in renal transplant patients.

OBJECTIVE: Kidney transplant recipients (KTRs) are bound to develop cardiovascular disease (CVD), and obesity represents a well-known risk factor for CVD. It has been reported that the metabolic syndrome (MetS) is a frequent finding in KTRs, and MetS could develop even if body mass index (BMI) is only mildly increased. We compared the impact of BMI and MetS on the development of major clinical events (MCEs) in a cohort of 107 KTRs during a follow-up of 63 ± 31 months. PATIENTS AND METHODS: Clinical characteristics were recorded at the time of enrollment and patients were classified on the basis of MCEs development. In a Cox model, MCEs were the dependent variable while age, sex, history of CVD, glomerular filtration rate, length of dialysis pre-transplantation, BMI classes and diagnosis of MetS were independent variables. Patients were classified into 3 groups: normal (BMI < 25 kg/m2), overweight (BMI of 25 to 30 kg/m2) and obese (BMI > 30 kg/m2). RESULTS: During follow-up, 55 MCEs were recorded: 16 patients died (15%), 19 (18%) had major cardiovascular events (CVEs), and 20 (19%) started dialysis due to graft failure. KTRs who had MCEs (n = 42) were older, had a lower renal function, longer dialysis vintage pre-transplantation, higher prevalence of history of CVD and higher BMI than those without MCEs. Cox regression analysis showed that length of dialysis pre-transplantation, renal function, previous CVD, and BMI classes (overweight and obesity) were related to MCEs. CONCLUSIONS: BMI, but not MetS, predicted MCEs in KTRs as well as non-traditional CVD risk factors such as length of dialysis pre-transplantation and graft function. Thus, a simple evaluation during clinic visits could identify KTRs at high risk for MCEs.

Behavioral response of brown meagre (Sciaena umbra) to boat noise.

Underwater man-made noise is recognized as a major global pollutant in the 21st Century, and its reduction has been included in national and international regulations. Despite the fact that many studies have pointed out the ecological impact of noise on marine organisms, few studies have investigated - in a field context - the behavioral response to boat noise in fish. In the present study we measure how Sciaena umbra reacts to boat noise. We found that boat noise: i) increased duration of flight reactions and number of individuals performing them, ii) increased the frequency of hiding behaviors, and iii) did not elicit a change in fish activity level and sound emission. Flights and hiding behavior, usually related to predation risk, were not uniform between individuals and showed a quick recovery after noise exposure. On the basis of these results, potential metabolic, physiological and behavioral consequences are discussed and management recommendations are proposed.

Inflammatory and Adipose Response in Solid Organ Transplant Recipients After a Marathon Cycling Race.

BACKGROUND: Organ transplant recipients frequently have chronic inflammation, with a weighty impact on cardiovascular risk. These patients can benefit from exercise, although the role of intense training is unclear. We evaluated the effect of a 130-km cycling race on inflammatory cytokines and adiponectin levels in transplant recipients. METHODS: Circulating interleukin (IL)-6, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, and adiponectin were assayed in 35 healthy subjects vs 19 transplant recipients (10 kidney, 8 liver, 1 heart), matched for sex, age, body mass index, and preparation workout. The determinations were performed before the race, at the end, and after 18 to 24 hours. Baseline values of 32 sedentary transplant recipients also were evaluated to explore the possible chronic impact of lifestyle. RESULTS: All cyclists had 6- to 8-fold increased IL-6 levels after the race that decreased, without returning to baseline, the day after. Conversely, serum TNF-α and IFN-γ showed a progressive increase starting during physical performance and enduring for the next 18 to 24 hours in healthy subjects, whereas they were unchanged over time in cyclists with transplants. In transplant recipients who did not perform exercise, all of the analytes were significantly higher in comparison to basal levels of physically active subjects. CONCLUSIONS: Our data suggest that clinically stable and properly trained transplant recipients can safely perform and progressively benefit from exercise, even at a competitive level. The changes in inflammation parameters were temporary and parallel with those of the healthy subjects. The comparison with sedentary transplant recipients revealed an overall amelioration of inflammatory indexes as a possible effect of regular physical activity on systemic inflammation.

The detrimental consequences for seagrass of ineffective marine park management related to boat anchoring.

Posidonia oceanica (L.) Delile meadows are recognized as priority habitat for conservation by the EU Habitats Directive. The La Maddalena Archipelago National Park (Mediterranean Sea) P. oceanica meadow, the dominant coastal habitat of the area, is mostly threatened by boat anchoring. 12 years after the establishment of mooring fields and anchoring restrictions, a study was conducted to measure their effectiveness on the conservation of seagrass and the mitigation of anchoring damage. We found that: (i) the condition of P. oceanica was disturbed, both in the mooring fields and in control locations; (ii) mooring fields and anchoring restrictions did not show to be an efficient system for the protection of seagrass, in fact anchor scars increased after the tourist season; (iii) the mooring systems had an impact on the surrounding area of the meadow, probably due to their misuse. On the basis of these results, management recommendations for marine parks are proposed.

The Kidney Donor Profile Index (KDPI) of marginal donors allocated by standardized pretransplant donor biopsy assessment: distribution and association with graft outcomes.

Pretransplant donor biopsy (PTDB)-based marginal donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the United States. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score<4 [median KDPI: 87; interquartile range (IQR): 78-94] and 62 with a score=4 [median KDPI: 87; IQR: 76-93]; 102 dual transplants [median KDPI: 93; IQR: 86-96]) and 248 single standard transplant controls (median KDPI: 36; IQR: 18-51). PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year estimated GFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9 and -18.8 mL/min, for dual transplants, single kidneys with PTDB score<4 and =4, respectively; p<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80-1.79; p=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded.

Tiempo de isquemia caliente y complicaciones postoperatorias después de la nefrectomía parcial de carcinoma de células renales / Warm ischemia time and postoperative complications after partial nephrectomy for renal cell carcinoma

Objetivo: Evaluar las correlaciones entre puntuaciones PADUA y RENAL, TIC y complicaciones postoperatorias en una cohorte de pacientes que se sometieron a cirugía de conservación de nefronas por elección abierta o mínimamente invasiva para el carcinoma de células renales. Material y métodos: Analizamos 96 pacientes consecutivos que fueron sometidos a nefrectomía parcial por carcinoma de células renales entre 2004 y 2013 en nuestra institución. La prueba de Spearman se utilizó para comparar variables categóricas. Para todos los análisis estadísticos un valor de p < 0,05 de 2 caras se consideró estadísticamente significativo. Resultados: La mediana de puntuación PADUA (RI) fue de 7 (7-8) y la puntuación RENAL mediana (RI) fue de 7 (6-8). La mediana de tiempo de isquemia caliente (RI) fue de 14 min (8-20). Se encontraron complicaciones postoperatorias de grado bajo y alto en 27 (28,1%) y 6 (6,3%) pacientes, respectivamente. Las categorías de grupos de riesgo de PADUA se correlacionaron significativamente con TIC > 20 min y las complicaciones postoperatorias de alto grado, respectivamente (p = 0,04), independientemente del abordaje quirúrgico. Las categorías de grupos de riesgo RENAL predijeron significativamente más tiempo de pinzamiento hiliar en nuestra cohorte (p = 0,04), pero no se encontraron correlaciones estadísticamente significativas con las complicaciones postoperatorias de alto grado. Conclusiones: En nuestra serie retrospectiva las puntuaciones nefrométricas demostraron predecir significativamente mayor tiempo de isquemia caliente y mayores complicaciones postoperatorias, especialmente en aquellos pacientes con tumores renales más difíciles y complejos. Por lo tanto, al planificar realizar la nefrectomía parcial los urólogos deberían utilizar ampliamente estas herramientas completas

Objective: To evaluate the correlations between PADUA and RENAL scores, WIT and postoperative complications in a cohort of patients who underwent elective open or minimally invasive nephron sparing surgery for renal cell carcinoma. Materials and methods: We analyzed 96 consecutive patients who underwent partial nephrectomy for renal cell carcinoma between 2004 and 2013 at our Institution. The Spearman test was used to compare categorical variables. For all statistical analyses, a two-sided p < 0.05 was considered statistically significant. Results: The median (IQR) PADUA score was 7 (7-8) and the median (IQR) RENAL score was 7 (6-8). The median (IQR) warm ischemia time was 14 min (8-20). Low grade and high grade postoperative complications were found in 27 (28.1%) and 6 (6.3%) patients, respectively. PADUA risk group categories significantly correlated with WIT > 20 min and high grade postoperative complications, respectively (p = 0.04), regardless of the surgical approach. RENAL risk group categories significantly predicted longer hilar clamping time in our cohort (p = 0.04), but no statistically significant correlations with high grade postoperative complications were found. Conclusions: In our retrospective series nephrometric scores demonstrated to significantly predict longer warm ischemia time and higher postoperative complications, especially in those patients with more challenging and complex renal tumors. Therefore, when planning to perform partial nephrectomy, urologists should widely use these comprehensive tools

Warm ischemia time and postoperative complications after partial nephrectomy for renal cell carcinoma.

OBJECTIVE: To evaluate the correlations between PADUA and RENAL scores, WIT and postoperative complications in a cohort of patients who underwent elective open or minimally invasive nephron sparing surgery for renal cell carcinoma. MATERIAL AND METHODS: We analyzed 96 consecutive patients who underwent partial nephrectomy for renal cell carcinoma between 2004 and 2013 at our Institution. The Spearman test was used to compare categorical variables. For all statistical analyses, a two-sided P < .05 was considered statistically significant. RESULTS: The median (IQR) PADUA score was 7 (7-8) and the median (IQR) RENAL score was 7 (6-8). The median (IQR) warm ischemia time was 14 min (8-20). Low grade and high grade postoperative complications were found in 27 (28.1%) and 6 (6.3%) patients, respectively. PADUA risk group categories significantly correlated with WIT > 20 minutes and high grade postoperative complications, respectively (P = .04), regardless of the surgical approach. RENAL risk group categories significantly predicted longer hilar clamping time in our cohort (P = .04), but no statistically significant correlations with high grade postoperative complications were found. CONCLUSIONS: In our retrospective series nephrometric scores demonstrated to significantly predict longer warm ischemia time and higher postoperative complications, especially in those patients with more challenging and complex renal tumors. Therefore, when planning to perform partial nephrectomy, urologists should widely use these comprehensive tools.

Renal transplant in patients with polycystic disease: the Italian experience.

We analyzed the results of kidney transplantation in autosomal dominent polycystic kidney disease (ADPKD) patients in Italy, including 14,305 transplantations performed from January 2002 to December 2010, including: 12,859 first single or double kidneys from cadaveric donors (13% polycystic), 172 combined liver-kidney cases (22% polycystic), and 1,303 living-donor organs (7% polycystic). Among the first transplantations (12,008 single, 851 double), with follow-ups ranging from 16 to 120 months, polycystic patients demonstrated better graft survival compared with other kidney diseases (86% vs 82% at 5 years; P < .01); mortality was not different (92% vs 79% at 1 year). A better trend was obtained also among combined liver-kidney transplantations in ADPKD. Regarding pretransplantation management of polycystic patients, we noticed a conservative attitude in 32/35 transplant centers. The main indication for nephrectomy was for the lack of abdominal space. Regarding instrumental studies, 86% of centers asked for second-level investigations computerized tomography for kidney dimensions. Radiologic investigations for vasculocerebral malformations were required in 97% of the centers: 74% as a routine and 23% in the presence of familial history of cerebral hemorrhage. Polycystic patients are good candidates for kidney transplantation with correct management before transplantation.

Incidence of late deep venous thrombosis among renal transplant patients.

BACKGROUND: Kidney transplant recipients (KTRs) manifest hypercoagulable state that contributes to an increased incidence of deep vein thrombosis (DVT), not only early but also late in their course. KTRs display an imbalance of hemostatic mechanisms with a multifactorial rise in procoagulant factors, partly related to traditional risk factors and partly to transplantation. The aim of this study was to evaluate the incidence of first episodes of DVT among KTRs, focusing on risk factors. METHODS: From 2008 to 2011, we evaluated 30 kidney transplant patients who ≥4 months there after transplantation developed DVT in the lower limbs only, lower limbs complicated by pulmonary embolism or retinal thrombosis. We analyzed causes of primary nephropathy, immunosuppressive regimen, post-transplantation infections, and erythrocytosis. DVT was diagnosed by color Doppler ultrasound or eye examination. RESULTS: A significantly increased incidence of DVT was observed among patients receiving cyclosporine or cyclosporine + mammalian target of rapamycin inhibitors, affected by polycystic kidney diseases, systemic lupus erythematosus or nephrotic syndrome, or displaying rapid and/or excessive correction of hematocrit values. DVT was not significantly related to an acute infection (cytomegalovirus) or to the prior dialysis modality. CONCLUSIONS: Hypercoagulability is a multifactorial condition in KTRs, representing a severe complication in stable patients. Prevention may consist of either accurate pretransplantation screening for thrombophilia or identification of patients at higher DVT risk.

Family recurrence and oligo-anuria predict uremic restless legs syndrome.

OBJECTIVES: To determine clinical and laboratory predictors of restless legs syndrome (RLS) in patients with end-stage kidney disease (ESKD) undergoing long-term hemodialysis (HD). MATERIALS AND METHODS: One hundred and sixty-two consecutive patients were assessed. History of sleep disturbances, neurological examination, clinical, and laboratory data were collected. Patients with and without RLS were compared, and a logistic regression model described the relations between independent predictors and RLS. RESULTS: Fifty-one patients (32%) currently had RLS (RLS+). RLS+ vs RLS- patients were more frequently women (49% vs 29%, P = 0.012), had first-degree relative with RLS (22% vs 6%, P = 0.004), insomnia (59% vs 36%, P = 0.007), peripheral neuropathy (41% vs 21%, P = 0.006), and low residual diuresis (92% vs 68% with below 500 ml/24 h, P = 0.001). Low (OR = 8.71, CI = 2.27-33.41; P = 0.002) and absent (OR = 4.96, CI = 1.52-16.20; P = 0.008) residual diuresis, peripheral neuropathy (OR = 4.00, CI = 1.44-11.14; P = 0.008), and first-degree relative with RLS (OR = 3.82, CI = 1.21-12.13; P = 0.023) significantly predicted RLS in ESKD patients undergoing HD. CONCLUSION: Positive family history for RLS together with reduced/absent residual renal function and peripheral neuropathy predicts the risk for RLS in ESKD patients undergoing HD. Longitudinal studies are warranted to correlate RLS occurrence with genetic and environmental factors.

A very early and acute renal impairment due to polyomavirus allograft nephropathy.

Polyomavirus-associated nephropathy (PVAN) has become an important cause of graft loss in the last few years. The typical course of PVAN is characterized by an asymptomatic period of viruria followed, within weeks, by the development of viremia in the context of stable renal function. The persistence of viral replication characterized by high viremia, leads to parenchymal injuries and causes the development, within months, of PVAN that could lead to deterioration in graft function and graft loss. We reported, in a patient who received a renal transplant, an unusual presentation of PVAN characterized by the development of acute renal failurte earlier than would be expected after transplantation, where the histological presentation alone could be confused with an acute rejection. We underline the importance of the association of histological findings with the viral load in urine and blood and with ancillary techniques such as immunohistochemistry and polymerase chain reaction (PCR) in situ for virus detection. We also want to emphasize that decoy cells and PCR for BK virus DNA research could be considered among the diagnostic tools for possible acute renal failure in kidney transplant.

A case of Paget's disease in hemodialysis.

Paget's disease is the second most common bone disease after osteoporosis and causes an excessive bone turnover. Moreover, chronic kidney failure causes an impairment of bone mineral metabolism and electrolytes and PTH homeostasis. As far as we know, this is the first reported case of Paget's disease in a hemodialysis patient: the patient was also affected by secondary hyperparathyroidism and was successfully treated with clodronate, cinacalcet and paracalcitol. The safety and efficacy of this combined therapy was periodically revised in a 12-month follow-up considering the common markers of bone turnover as well as the dosage of OPG, RANKL, IL-6 and MCSF, involved in the pathophysiology of Paget's disease.

The cardiovascular burden of end-stage renal disease patients.

Patients with end-stage renal disease are 10 to 20 times more at risk of cardiovascular death than the general population. Traditional cardiovascular risk factors are not able to explain the increase in the onset of cardiovascular diseases in dialysis patients. Some of the most important non traditional risk factors in uremic patients are: the inflammatory state of the patients, cytokines and growth factors, hyperhomocysteinemia, the presence of alterations of the calcium phosphorous product which can already be in progress when the glomerular filtration rate decreases to less than 60 mL/min. Clinically, these alterations cause vascular calcifications, calcifications of the heart valves and calcific uremic arteriolopathy or calciphylaxis. The pathogenesis of vascular calcification is complex and cannot be assigned to a simple, passive process: in fact, it includes factors which promote or inhibit calcification. In turn, these pathologic conditions have been found to be highly predictive of general and cardiovascular death. Given the serious clinical consequences that vascular calcifications can cause, it is necessary to carry out an early mapping of the traditional and non traditional risk factors of uremic patients as it seems that therapeutic interventions aimed at reducing or inverting the calcification process can improve the outcome of patients, above all when they are started quickly.