Pancreas transplantation inside Emilia-Romagna, Italy: referral pattern, demand forecasting, and organ availability.

In Italy, referral of diabetic patients for pancreas transplantation (PT) is an unstructured process, resulting in a low rate of activity and late referrals, often when the patient has already undergone dialysis. In addition, the continuous improvement in pancreas transplant alone, offering the opportunity to reduce cardiovascular risk due to proteinuria and reduced glomerular filtration rate (GFR), is rarely appreciated. We therefore analyzed (1) referral activity to PT during the time frame 2001-2005 in Emilia-Romagna, Italy (four million inhabitants), by collecting ICD 9 CM codes (55.69 + 52.80; 52.86 and 52.80 alone) by residence of the patient; (2) demand for PT among a sample population of 1670 diabetes patients, whose charts were reviewed for the type of diabetes and presence of overt diabetic nephropathy (DN: proteinuria >300 mg/24 h and/or GFR <60 mL/min); (3) potential pancreas availability as the ratio between pancreas and hearts utilized (UP/HR) in different areas of our country. As a results, (1) referral activity reached 8.4 PT per million people in 5 years in the whole region, ranging from 2.6 in the province where a PT program is active, to a maximum value of 20.7 in the province where a devoted outpatient clinic is operated by nephrologists. (2) Prevalence of overt DN was 6% in our cohort, corresponding to 510 D1 patients worthy of evaluation for PT inside Emilia-Romagna region. (3) During 2006, UP/HR was 0.58 in Associazione Inter-Regionale Trapianti agency, 1.16 in Tuscany, 0.30 in Piedmont, and 0.26 in our region. Taken together, our data showed that (1) the referral of D1 to PT has to be empowered, keeping in touch with all patients suffering from diabetic nephropathy; (2) the outpatient clinic devoted to evaluation and recruitment of D1 with nephropathy plays the key role in this program of timely and widespread referral; (3) the availability of pancreata can be increased by utilizing broader criteria for harvesting, increased consent rate to donation and increased the demand for PT (recipient pool). Pancreas grafts need to increase, since the current low demand produces underutilization of the pancreas resource, due to the frequent lack of a suitable recipient.

["Terzo fuoco", lead poisoning and chronic renal failure]. / "Terzo fuoco", intossicazione da piombo e insufficienza renale cronica.

BACKGROUND: In ceramics, "Terzo fuoco" (Third fire) means a third firing of clay to fix colors on tiles or pottery. The low firing temperatures (800-900 degrees C) and the use of a spray gun are risk factors for lead poisoning. Because of their small size, handicraft companies often fail to implement the preventive measures that are utilized efficiently in large tile factories. We report a case of chronic lead poisoning with special emphasis on diagnostic tools and treatment goals. CASE REPORT: A 38-year-old woman was hospitalized in 2005 because of grade 3 chronic renal failure (serum creatinine 1.69 mg%, Cockroft-Gault glomerular filtration rate [GFR] 45 mL/min), hypertension and elevated serum uric acid (13.4 mg%) without gout. She had been previously hospitalized elsewhere and diagnosed as suffering from hypertensive nephropathy. Her occupational history included acute lead poisoning 12 years before, which was treated with a short leave from work. She subsequently continued her job, using a spray gun for decorative drawing in a small tile company until 2004. Because of a low GFR she underwent a 3-day chelation test with 750 mg CaNaEDTA i.v., and excreted 1056 microg Pb (n.v < 600 microg) -- (PbU/EDTA ratio 1.41; n.v < 0.6). A renal biopsy showed chronic interstitial nephropathy with severe arteriolosclerosis. The patient was treated with 5 courses of EDTA, resulting in a final Pb excretion of 517 microg/72 h (PbU/EDTA 0.69). Her serum creatinine fell to 1.32 mg% (CFR 58 mL/min). A further course of chelation therapy is planned. DISCUSSION AND CONCLUSIONS: The EDTA chelation test allows to determine the lead body burden (PbBB) and to titrate subsequent chelation therapy. Recent papers have shown that PbBB is a major factor in the progression of chronic renal failure besides pressure control, and have indicated a PbBB safety level of less than 100 microg/test (PbU/EDTA < 0.1). In order to prevent the development of chronic renal failure, it is important that not only occupational but also environmental lead exposure be identified and adequately treated.

Dialysis-related amyloidosis: challenges and solutions.

Amyloidosis refers to the extracellular tissue deposition of fibrils composed of low-molecular-weight subunits of a variety of proteins. These deposits may result in a wide range of clinical manifestations depending upon their type, location, and the amount of deposition. Dialysis-related amyloidosis is a serious complication of long-term dialysis therapy and is characterized by the deposition of amyloid fibrils, principally composed of ß2 microglobulins (ß2M), in the osteoarticular structures and viscera. Most of the ß2M is eliminated through glomerular filtration and subsequent reabsorption and catabolism by the proximal tubules. As a consequence, the serum levels of ß2M are inversely related to the glomerular filtration rate; therefore, in end-stage renal disease patients, ß2M levels increase up to 60-fold. Serum levels of ß2M are also elevated in several pathological conditions such as chronic inflammation, liver disease, and above all, in renal dysfunction. Retention of amyloidogenic protein has been attributed to several factors including type of dialysis membrane, prolonged uremic state and/or decreased diuresis, advanced glycation end products, elevated levels of cytokines and dialysate. Dialysis treatment per se has been considered to be an inflammatory stimulus, inducing cytokine production (such as interleukin-1, tumor necrosis factor-α, interleukin-6) and complement activation. The released cytokines are thought to stimulate the synthesis and release of ß2M by the macrophages and/or augment the expression of human leukocyte antigens (class I), increasing ß2M expression. Residual renal function is probably the best determinant of ß2M levels. Therefore, it has to be maintained as long as possible. In this article, we will focus our attention on the etiology of dialysis-related amyloidosis, its prevention, therapy, and future solutions.

Stenosis after stapler anastomosis.

Two cases of anastomotic stenosis after the use of the GIA Auto Suture Stapler are presented as examples of the potential problem that does exist in using this instrument. Possible causes and a suggestion for eliminating this complication have been outlined.

A favorable 3-year outcome of kidney transplantation in atypical hemolytic uremic syndrome associated with a factor H mutation: case report.

Complement factor H (CFH)-associated hemolytic uremic syndrome (HUS) is a genetic form of atypical HUS characterized by deficient CFH levels or activity, which cause a disorder of the regulation of the alternative pathway, leading to uncontrolled complement activation. This genetic disorder, which frequently leads to end-stage renal failure, often recurs in kidney transplants, resulting in the poorest graft outcomes among all atypical HUS forms, due to a mutation in genes encoding complement components and regulatory proteins. Herein we have report our experience with a 40-year-old woman, suffering from a clearly defined sporadic form of genetic atypical HUS, consisting of a heterozygous missense mutation in factor H gene. She underwent cadaveric kidney transplantation. At the moment of surgery she displayed positive hemolysis indices and C3 consumption. A calcineurin inhibitor (CNI)-free immunosuppressive regimen was based on sirolimus, mycophenolic acid and steroids after basiliximab induction. An early and intense prophylactic course of plasma exchange (PE), and fresh frozen plasma (40 mL/kg) was prescribed, starting before surgery and continuing daily for the first week. The frequency of PE slowly reduced over the following 2 weeks. After that, just plasma infusion at the same dose was performed once a week until 12 weeks after transplantation. There was prompt graft function and in third week there were no signs of hemolysis or of C3 consumption. More than 3 years after transplantation, the graft is still functioning well and there was no recurrence. In our opinion, this case indicates that, although evidence is lacking, avoidance of CNI and intensive prophylactic plasma therapy are essential to achieve good results in this peculiar type of kidney transplantation. Nevertheless, controlled, prospective studies are necessary to establish the actual role of these two therapeutic procedures in renal transplantation of patients with CFH-associated HUS.

Pancreatic liposarcoma: case report with review of retroperitoneal liposarcomas.

A case report of a large pancreatic liposarcoma is presented showing a five-year survival with aggressive surgical excision as the only treatment. The medical literature of the subject is reviewed. This is the only reported case of retroperitoneal liposarcoma which is limited to the pancreas. A discussion of the current types of treatment for retroperitoneal liposarcomas is included.

The use of paper tape in wound closures.

The techniques described using paper tape in wound closure have been found to be cosmetically equal to or better than other forms of wound closure. Paper tape provides better support, is more versatile and care free, while being easier to use and less expensive than Steri Strips.