Color Doppler Imaging Study in Patients with Primary Open-Angle Glaucoma Treated with Timolol 0.5% and Carteolol 2%

Purpose

To evaluate with color Doppler imaging (CDI), in patients with primary open-angle glaucoma (PDAG), the possible influence on ocular hemodynamics of a beta-blocking agent with intrinsic sympathomimetic acitivity (carteolol 2%) compared to a beta-blocker agent without this activity.

Methods

A study was carried out on 20 patients, with bilateral POaG, intraocular pressure (IOP) ≤ 20 mmHg, all treated twice a day with timolol maleate 0.5% ophthalmic solution. The visual field was evaluated (Octopus 2000 perimeter, G1 program) examining the mean sensitivity (MS) and the mean defect (MD). CDI was carried out to evaluate the resistance index of the internal carotid artery (ICA), the ophthalmic artery (OA), the central retinal artery (CRA), and the short posterior ciliary arteries (SPCA). After these examinations, the therapy was changed to carteolol 2% twice a day. After six months of treatment the examinations were repeated. The data were analysed statistically using Student's t test.

Results

The mean intraocular pressure during treatment with timolol 0.5% was 16.7 ± 1.67 mmHg and 16.33 ± 1.72 mmHg after treatment with carteolol 2%, the difference not being significant (p=0.494). After six months of treatment with carteolol 2% the MS increased significantly from 22.4 ± 2.5 dB to 24.1 ± 1.8 dB (p=0.018), and the mean defect (MD) fell from 5.3 ± 0.8 dB to 4.7 ± 0.6 dB (p=0.011). There was no significant difference in the resistance index of the CA, the OA and the CRA with the two treatments, whereas the resistance index of the SPCA dropped significantly, from 0.80 ± 0.05 to 0.77 ± 0.02 (p = 0.017).

Conclusions

CDI did not show significant differences in the resistance indexes of the internal CA, the OA, and the CRA after treatment with carteolol 2% but the resistance index of the SPCA was significantly reduced. Carteolol 2% induced significant changes in the perimetric indexes examined, with an increase in MS and a decrease in MD. These findings suggest that the intrinsic sympathomimetic activity of carteolol may reduce peripheral vascular resistance of the SCA, thus improving perfusion of the optic nerve head, with a protective effect on visual function.

Gastrointestinal Side Effects of Post-Transplant Therapy

Modern immunosuppressive therapy has produced a real revolution in renal and organ transplantation but it comes with the price of multiple side effects. There are many gastrointestinal (GI) complications that are the consequence of transplant immunosuppressant medication. In fact, for any immunosuppressant therapy, certain standardized precepts and attitudes that aim to reduce the incidence and the impact of the medication side effects must be applied. Many patients undergo renal transplantation and the physicians have to be aware of the advantages and the risks associated. This article reviews the main GI complications that may arise as a consequence of immunosuppressive therapy after solid organ transplantation, focusing on renal and renal/pancreas transplantation, as well as the ways in which the incidence of these complications can be reduced. Management of the post-transplant therapy is mandatory in order to increase not only the grafts' and the patients' survival, but also their quality of life by the occurrence of fewer complications.

[Surgical overview on kidney and pancreas transplantation]

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.

Malignancies in 2,753 kidney recipients transplanted during a 39-year experience

An increased development of malignancies has been related to modern potent antirejection drugs. The purpose of this retrospective study was to assess the incidence and risk factors for invasive malignancies among 2753 kidney recipients (KRs), who were transplanted in two periods within our 39-year experience; before (group I) versus after (group II) the introduction of calcineurin inhibitors (CNIs). In group I, formed by 703 KRs under conventional therapy, 45 (6.4%) patients developed a malignancy, while in group II, treated with CNIs, of over 2050 KRs, 182 (8.9%) developed a malignancy different from noninvasive skin cancer. The incidence of malignancies was higher in the group of patients treated with CNIs (8.9% vs 6.4%), despite the shorter follow-up period. Moreover, the malignancy was more precocious in the CNI group, namely a mean time of onset of 75 versus 154 months in the conventionally treated group. The older mean age of recipients in group II affected by malignancies (43.6 years vs 34.6 years of the group I) played a significant (P < .001) role when associated with the more powerful immunosuppressive effect of CNIs, while recipient gender, dialysis period, donor source, and retransplants seemed to have few effects on malignancy development. Recipients over 60 under CNIs showed a 21% incidence of malignancies.

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.

The role of immunosuppression in malignancies among 351 pediatric renal transplant patients

The incidence of de novo malignancies over a 38 year experience in 351 children ranging in age from 2 to 18 years was investigated among subjects prescribed various immunosuppressive protocols. There were 14 children (3.98%) who showed de novo malignancies, namely, 4.86 cancers for every 1000 graft-function years (GFYs). Among patients who had grafts functioning for >10 years, 7.4% suffered from cancer. Nine patients survive without a recurrence at a mean of 12.5 +/- 6.6 years including 6 with graft function. Among group I who were treated with pre-calcineurin inhibitor (CNI) therapy 3 (3.8%) children (1 male and 2 females) developed a malignancy at a mean of 15.2 +/- 11.9 years posttransplant (range, 7-35), for 4.65 cancers every 1000 GFYs. Two of them survive with functioning grafts. Among group II, who were treated by CNIs there were 273 children including 24 retransplants. Group II showed 11 malignancies (4.0%), for 5.04 malignancies for every 1000 GFYs. The incidence of cancer was similar in the 2 groups, undergoing different immunosuppressive regimens; however, the malignancies in the CNI- group were more precocious, compared with those of the conventionally-treated cohort.

Arteriovenous fistula as stable venous access in children with severe haemophilia

Treatment for children with severe haemophilia is based on prophylaxis and, if inhibitors occur, on immune tolerance induction (ITI). Both regimens require frequent infusions at early ages and therefore an adequate venous access is essential. Peripheral veins represent the best option; however, central venous catheters (CVCs) have been used to facilitate regular treatment. Unfortunately, survival of CVCs is affected by infectious and/or thrombotic complications that often lead to premature removal and consequent treatment discontinuation. This aspect may have an impact on treatment outcome, especially in the case of ITI. In light of this, internal arteriovenous fistula (AVF) has been proposed as an alternative option because of a lower rate of infectious complications. Moreover, AVF is easy to use in the home setting and is well accepted by children and parents. The possible complications are postoperative haematoma and transient symptoms of distal ischaemia; one case of symptomatic thrombosis has been reported to date. Other complications include loss of patency, aneurysmatic dilatation and limb dysmetria. A regular follow-up is mandatory to allow early remedial interventions. Surgical AVF dismantlement is recommended as soon as transition to peripheral vein access is possible.

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.

The endless history of vascular access: a surgeon's perspective

Gaining access to blood circulation has been a major breakthrough of modern medical care and, despite the evolution of dialysis technology, vascular access (VA) remains the main impediment in providing quantity as well as quality of life to the end-stage renal disease (ESRD) patient. The external Scribner shunt and the internal Brescia/Cimino arteriovenous fistula (AVF) opened the way for further advancements such as graft angioaccess and other sophisticated devices. Forty years later, the radio-cephalic fistula remains the VA with the longest patency and the lowest complications. Although various technical solutions can be adopted for constructing access to the patient's vessels, the nephrologist must bear in mind that every VA in the upper limb, lower limb or body wall needs a run-in and a run-off: currently, thrombosis of the central vessels due to the excessive widespread use of central venous catheters (CVCs) emerge as a substantial cause of hemodialysis (HD) morbidity and mortality. Moreover, as there is a risk of central vein stenosis, even 2 weeks after catheter placement, and an impaired venous outflow precludes the creation of any VA and sometimes the placement of a kidney transplant in the iliac fossa for many years, we agree with McGill et al, who in 2005 said that ''expansion of catheter access may contribute to the reduced survival of hemodialysis patients in the United States''.

Combined liver-kidney transplantation in glycogen storage disease Ia: a case beyond the guidelines

Glycogen storage disease type Ia (GSD Ia) is a rare metabolic disorder due to hepatic glucose-6-phosphatase deficiency. Although great progress has been made in managing affected patients, severe hypoglycemia, lactic acidosis, hyperlipidemia, hepatic cytolysis, and impaired kidney function are frequent. Liver transplantation is the only radical treatment, for which the main indications are hepatic adenomatosis, hepatocellular carcinoma, or severe hepatic dysfunction. We present the case of a patient with end-stage renal disease without focal hepatic lesions and with moderate hepatic metabolic control, and we explain how combined liver-kidney transplantation (LKT) made it possible to correct the metabolic defects responsible for the impaired glucose homeostasis, liberalize the diet, and give birth to a healthy child after an uneventful pregnancy. Patients with end-stage renal disease that resulted from GSD Ia should be considered for LKT even in the absence of hepatic lesions with the aim of improving their quality of life.

Immediate graft function positively affects long-term outcome of renal allografts from older but not from younger donors

There is disagreement about the impact of delayed graft function (DGF) on renal allograft outcome. This may depend on several variables including the age of the donor. We evaluated whether DGF could have different effects in recipients of kidneys from donors aged more than 60 years versus well-matched recipients of younger kidney donors. Patients were retrospectively subdivided into 3 groups. Immediate graft function (IGF), DGF without dialysis (DGF-ND), DGF requiring dialysis (DGF-D). DGF-ND and DGF-D occurred more frequently among 198 older than 198 younger donors (P = .016 and P = .044, respectively). The 5-year patient (96% vs 93%) and pure graft (96% vs 89%) survivals were significantly better in younger recipients, while the incidence of acute rejection was similar. After a mean follow-up of 66 +/- 44 months in older donor recipients, the graft survival was significantly better among IGF than patients in the DGF-ND (P = .046) or DGF-D (P = .003) groups. Instead, in younger recipients there was no difference in graft survival between IGD and DGF-ND. Only patients with DGF-D showed a significantly worse outcome. Upon multivariate analysis of older donors, their recipients, showed the pattern of graft function recovery to be the only variable associated with allograft outcome. Instead in younger donor recipients, acute rejection and time on dialysis were the main variables associated with a poor outcome. In older donor recipients, DGF was an independent variable associated with a poor graft outcome. In younger donor recipients, duration of dialysis and rejection were the most important predictors of poor graft outcomes.

Best Results in Living Donor Transplantation Using an Aggressive Policy in Microsurgical Bench Reconstruction of Nonoptimal Arterial Supply

The increasing of number of patients awaiting kidney transplantation have forced surgeons to use nonoptimal organs, such as kidneys with multiple/diseased arteries as well as those coming from living donors (LDs). Two hundred and sixty six LD transplants performed in cyclosporine era included 44 coming from a LD over 60 years of age. They were categorized into three groups according to the number of renal arteries and the surgical techniques employed for the arterial anastomosis: group I (n = 213) had a single "normal" renal artery. Group II (n = 11) were grafts with two (n = 10) or three (n = 1) arteries, which were directly reconstructed by intracorporeal conventional separate anastomoses. Group III of 42 recipients had grafts with either one artery affected by intrinsic renovascular disease (n = 18) or multiple arteries (n = 24) that were reconstructed at the bench. Recipient survival at 1 year was comparable, namely, 98%, 100%, and 100% rates in groups I, II, and III, respectively. Graft survivals not censored for death were 87%, 85%, 100% at 3 years for groups I, II, and III, respectively. The use of microvascular reconstructions ex vivo can widen the criteria for acceptance of LDs who display multiple or diseased renal arteries.

Grafts and graft materials as vascular substitutes for haemodialysis access construction

Apart from long-term central venous catheterisation, the insertion of an arteriovenous graft (AVG) remains the only option to allow continued haemodialysis when the patient's superficial veins have been exhausted. Although, expanded PTFE has become the graft of choice for haemodialysis access throughout the world, many other organic or semi-organic materials are currently available for AVG construction. These are less prone to steal syndrome, easier to handle, more resistant to infection and may have similar, if not better, long term patencies.

Value of Intraoperative Resistive Index in Kidney Transplant

The value of the resistive index (RI) obtained by echo color doppler evaluation of the transplanted kidney is still not well established. Many authors consider the RI to be nonspecific sign of rejection, acute tubular necrosis, or urinary tract obstruction, but its specificity remains low. In this paper, we report our experience with RI determinations in 34 consecutive kidney transplants at different times namely: perioperatively, at 24 hours, at 3 days, at 6 and at 9 days posttransplant. In all patients intraoperative RI was normal. RI increased significantly after transplantation in 10 patients who eventually developed a complication: delayed function, acute rejection, and spontaneous kidney ruptures. This increment from the baseline value was already significant at 24 hours after the kidney transplant, indicating a possible posttransplant complication (0.62 +/- 0.07 vs 0.76 +/- 0.04; P = .0004). We conclude that the value of RI in the early posttransplant phase should be considered an important aid for the early diagnosis of posttransplant complications.

Technical Problems in Living Donor Transplantation

Inferior outcomes are generally described with grafts having multiple arteries or renovascular disease. A consecutive series of 261 living donor (LD) transplants performed in the CsA era was classified in three groups with regard to the graft arterial abnormalities and the techniques employed for revascularization. Two hundred eleven recipients had a kidney with one "healthy" renal artery (Group I); 11 patients, multiple arteries, which were reconstructed by various intracorporeal techniques (Group II); 39 patients, one diseased renal artery or multiple arteries, which were reconstructed on the bench (Group III). One- and 3-year graft survivals not censored for death, were 91%, 82%, 100% and 87%, 82%, 100%, respectively, for Group I, Group II, and Group III. An aggressive policy in performing microsurgical bench reconstruction, also for kidneys with one artery that are affected by intrinsic disease, allowed us to obtain a 3-year graft survival of 100% in our more recent consecutive series of 53 LD transplants.

Nosocomial Infection in Kidney Transplant Recipients: A Retrospective Analysis of a Single-Center Experience

Posttransplant bacterial infections are important because of their influence on patient and graft outcomes. Therefore, prevention of infection as well as prompt diagnosis and appropriate treatment are crucial. In this retrospective analysis, we reviewed all posttransplant bacterial infections occurring during the admission of kidney transplant patients from January 2000 to May 2004. Of our patients, 25% had at least one episode of infection. Patients with immunosuppression based on an mTOR inhibitor showed the highest rate of wound infections compared to those receiving a calcineurin inhibitor (odds ratio 5.6, P < .001). Patients with renal failure caused by a urologic disease revealed a increased risk of a urinary tract infections (odds ratio 5.9, P < .001). Although infection complications are an important cause of morbidity in renal transplantation, the extensive use of antibiotics should be avoided in favor of a strict policy for infection prevention and control.

C0 or C2 driven cyclosporine monitoring in long-term pediatric kidney transplant recipients: is there any threat for chronic rejection development?

The clinical management of cyclosporine has evolved greatly during the last decade thanks to the use of pharmacokinetic (PK) studies which confirmed the dose relationship between drug exposure and its biological effects. Therefore, cyclosporine PK monitoring during the early phase of the post-transplant period became essential to avoid over or underexposure to the drug thus preventing the risk of nephrotoxicity or acute rejection episodes. More recently, a simple PK determination based on cyclosporine blood concentration measured 2 h after the morning dose, has proven to be very effective for monitoring cyclosporine exposure in the early postoperative period. In this paper, the authors present a set of PK profiles obtained from a stable, long-term pediatric kidney transplant population and correlate these parameters with the risk of chronic rejection development. The study shows how cyclosporine monitoring based on the sole trough level determination misled a correct therapeutic behavior, as revealed by the PK parameters that were constantly below the therapeutic threshold in a small patient cohort who eventually developed chronic rejection. The C2 determination should be considered as the gold standard for cyclosporine monitoring in long-term pediatric recipients.

[Renal transplantation in the North Italy Transplant program (NITp): Organ allocation and results]

Renal transplantation is an effective therapeutic tool for patients with end-stage renal diseases (ESRDs). Data reported in this article summarize the results obtained from 30 years' activity in the North Italy Transplant program (NITp), the first transplant organization in Italy that implemented a donor procurement and organ transplantation network. In the NITp kidney allocation is governed by a computerized algorithm, NITK3, put in place in 1997, aimed at ensuring equity, transparency and traceability during the stages of the allocation decision-making process. The NITp working group has recognized the NITK3 criteria and they are periodically reviewed following the results of the analysis of patients' transplantation odds. The results obtained with the use of the NITK3 algorithm have been very satisfactory: after 6 yrs, a significantly higher percentage of patients at immunological risk (sensitized or waiting for re-transplant), of patients waiting for >3 yrs and of patients with 0-1 HLA A,B,DR mismatches have been transplanted. Moreover, a higher percentage of kidneys were used locally (in a hospital within the procurement area), and this is known to stimulate donor procurement. Finally, we performed a preliminary statistical analysis of transplants carried out from 1998-2002 in 5/16 centers of the NITp area, demonstrating the quality of the NITp program in terms of patient and graft survival, and that donor and recipient age are the variables significantly impacting on transplant results.

Renal transplantation. Strategies to prevent organ rejection--the role of an inter-regional reference center

This paper summarizes the role of the Inter-Regional Reference Center (RC) of the North Italy Transplant program (NITp), in coordinating a donor procurement and organ transplantation network, with a special focus on the strategies to minimize immunological risk and complications after transplantation. In the NITp, patients enrolled on the renal transplantation (RT) waiting list are typed for HLA-A,B,DRB1 antigens with a genomic method. They are periodically screened for the presence of lymphocytotoxic antibodies in their serum by the RC and their suitability to receive the transplant is checked periodically. Cadaver kidney allocation is ruled by a computerized algorithm, named NITK3, established in 1997, which aims at ensuring quality, equity, transparency and traceability during all the phases of the allocation decision-making process. NITK3 has been set up by the NITp Working Group on the basis of biological, medical and administrative criteria and it is periodically reviewed after the analysis of transplant results. In this paper, we show the results of a preliminary analysis of RTs performed from 1998 to 2002 in nine out of sixteen centers of the NITp area, which demonstrates the general quality of the NITp program in terms of patients and graft survival and the special attention to the patients at higher immunological risk.

C2 is an age-independent parameter for optimal cyclosporine exposure in long-term kidney transplant recipients

The argument for therapeutic drug monitoring (TDM) of cyclosporine (Cya) has been discussed for the last two decades. So far, a generalized consensus has been reached for TDM of Cya microemulsion in adult transplant recipients, being Cya blood levels obtained 2 hours after the administration (C2), the most reliable in reflecting the overall Cya exposure. However, clear guidelines are not available for the pediatric population because of the distinct metabolism of the drug in this patient population. Therefore, adult data do not necessarily apply to children. In this retrospective analysis, the authors sought to define a universal parameter for pharmacokinetic clinical monitoring of Cya in long-term kidney transplant recipients, regardless of their age. Lower C2 levels were observed in all patients, adult and pediatric, who eventually developed chronic allograft dysfunction (CRAD) compared with patients who maintained stable kidney function throughout the entire follow-up (pediatric CRAD, 933 +/- 455 ng/mL; vs Stable, 1236 +/- 347 ng/mL, P = .0001; and adult CRAD, 781 +/- 518 ng/mL; vs Stable, 1088 +/- 452 ng/mL, P = .009). On the other hand, the risk of Cya underexposure was not highlighted by trough level monitoring (C0) because all patients have been maintained steadily on therapeutical C0 levels for the entire follow-up. In conclusion, for Cya maintenance therapy, C2 appears to be a superior strategy to C0 monitoring in both adult and pediatric kidney transplant recipients.

Cyclosporine monitoring in stable, long-term, pediatric kidney transplant recipients: the value of C2 determination

Although a generalized consensus has been reached for therapeutic drug monitoring of cyclosporine microemulsion in adult transplant patients, clear guidelines are recently not available for the pediatric population. In this retrospective analysis of pharmacokinetic data obtained from stable, long-term, pediatric kidney transplant recipients, we sought to define a possible approach to manage cyclosporine therapy in a pediatric setting. The 2-hour postdose cyclosporine blood concentration, C(2), rather than trough levels, was the best single time point predictor of the area under the concentration curve. We concluded that therapeutic drug monitoring of cyclosporine-based immunosuppressive regimens should be tailored based on C(2) determinations for pediatric kidney transplant recipients.

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.

Early and long-term results using older kidneys from cadaver or living donors

The persisting shortage of organs for transplantation justifies the use of all possible donors. We compared results for 110 patients, who received solitary kidneys from cadaver donors over age 60 years (OCD) with those for 976 patients, who were transplanted with kidneys from 11-49-year-old cadaver donors, whom we defined as "ideal" age. Although the 4% incidence of primary nonfunction and the 24% rate of delayed graft function were significantly higher (p < 0.001) in the OCD group compared with the ideal group (0.8% and 8.0%, respectively), OCD kidneys can offer good results when low-risk recipients are carefully selected and the cold ischemia time is sharply reduced. Moreover, graft survival rates for 14 OCD grafts, implanted in patients under age 45 were 93% at one, 3 and 10 years compared with 79%, 74% and 42% at the same time points for 96 OCD recipients over age 45. The rate of delayed graft function was higher among 19 OCD grafts preserved for more than 20 hours, and these grafts yielded significantly lower survival rates than 91 OCD grafts preserved for less than 20 hours; with rates of 67%, 58% and 44% and 85%, 81% and 51%, respectively, after one, 3 and 10 years. Thirty-five kidneys from living donors over age 60 had comparable overall graft survival rates to living donor kidneys from donors under age 60 (92%, 92% and 92% vs. 92%, 88% and 80% at one, 3 and 10 years, respectively). An original point scoring system, based only on macroscopic evaluation of the graft, avoids the need for a biopsy and does not prolong cold ischemia time. Microvascular bench reconstructions of the renal artery, damaged by atherosclerosis, expand the possibility for safe transplantation of older kidneys without performing a double renal transplant.

Conversion from cyclosporine to tacrolimus in pediatric kidney transplant recipients

In pediatric kidney transplant recipients, tacrolimus has been proposed either for primary immunosuppression or as a rescue agent for refractory acute rejection, chronic rejection, and cyclosporine toxicity. This paper describes our experience with tacrolimus conversion from cyclosporine-based therapy in six selected cases: four due to refractory acute rejections unresponsive to conventional therapy, one to chronic graft rejection, and one to cyclosporine-related hypertrichosis. A "simple-switch" conversion was used without any overlap, starting with a dose of 0.2 mg/kg per day. The time to conversion varied from 10 to 730 days after the transplant. In the patients with acute rejection, the median time to reversal after tacrolimus conversion was 12 days. The symptoms of the patient with cyclosporine toxicity completely resolved without any loss of allograft function. The patient with chronic rejection maintained stable renal function for more than 1 year after conversion. A new onset of post-transplant diabetes mellitus and dose-related nephrotoxicity were recorded as adverse events. In conclusion, our experience suggests that tacrolimus can play an important role in the salvage treatment of pediatric kidney transplantations with deteriorating graft function due to acute rejection refractory to standard therapy. Tacrolimus conversion also provides excellent results in the presence of cyclosporine toxicity.

[Living-donor kidney transplantation in the cyclosporine era]

BACKGROUND

Renal transplantation is the best possibile form of treatment for chronic renal failure. It offers the patient a longer life expectancy when compared to dialysis. Aim of the study was to evaluate our results with live donor transplantation and the variables that influenced the long-term patient and graft survival.

METHODS

190 patients received a live donor kidney transplantation in our Hospital between 1984 and 2000. Thirty-eight of them received a graft from an HLA identical donor, 130 from an HLA haploidentical donor, 22 from a living unrelated donor (spouse). Fourteen patients underwent a pre-emptive transplantation. Aim of the study was to evaluate which variables could influence the long-term patient and graft survival.

RESULTS

The median follow-up of recipients was 69.5 months. The 10-year patient and graft survival were 94.7% and 73.4% respectively. Graft half-life was 29.6 years. Six patients died. Twelve patients lost their graft because of vascular thrombosis and five patients because of rejection within the first six months. After the first year, 11 patients lost their graft because of chronic rejection and 4 after recurrence of the original disease. One hundred and forty-four patients are still under observation, and at the last examination their mean plasma creatinine was 2.0+/-1.1 mg/dl. At univariate statistical analysis the absence of locus DR incompatibility was associated with a trend toward a better long-term survival of both patient and graft (P=0.05), while less than one year of dialysis showed a significantly better survival rate (P < 0.01).

CONCLUSIONS

Living-donor transplantation offers an excellent long-term patient and graft survival.

Successful renal transplantation in children under 6 years of age

To evaluate the efficacy of renal transplantation in small pediatric patients, we have reviewed 41 allografts performed in 39 children (28 M/11 F) less than 6 years of age between 1987 and 1998 in the North Italy Transplant Program. Of these patients, 39 had a cadaver donor and 2 a living-related donor, with ages ranging from 20 days to 35 years. The mean follow-up was 56 months. Graft survival was 74.5% and 70.5% at 1 and 5 years, respectively. The causes of graft lost were acute rejection (4), graft vascular thrombosis (4), and hemolytic uremic syndrome recurrence (1). Only 1 patient has died due to chickenpox. Double and triple immunosuppressive therapies were used in 63% and 37% of patients, respectively, on the basis of different center protocols, without differences in graft survival. Steroids were successfully administered on alternate days in 37% of patients, 6-12 months after transplantation. Thrombosis was reported in 2 of 6 kidneys from donors less than 1 year of age and in 2 of 35 donors older than 1 year (P < 0.05). Thirty rejections occurred in 23 patients: 7 episodes were steroid resistant and were treated with ATG/OKT3. Thirty-four infections were reported in 16 of 41 patients; of these 17 were viral, 14 bacterial, and 3 due to Mycoplasma. Four surgical complications were reported: 1 graft artery stenosis, 1 ureteral stenosis, 1 urinary leak, and 1 lymphocele. Mean height standard deviation score improved from -2.0 +/- 1.3 pre transplantation to -1.8 +/- 1.4, -1.5 +/- 1.3, and -1.5 +/- 1.5 at 1, 2, and 5 years post transplantation. Linear growth was significantly better in infants treated with alternate-day steroids. Hypertension was a frequent complication, since 19 of the 30 patients with a 5-year follow-up were still being treated with antihypertensive drugs. In conclusion, graft survival in patients less than 6 years old is satisfactory and similar to that obtained in children aged from 6 to 18 years (70.5% vs. 78.9% at 5 years, P = NS). Consequently, since there are many difficulties in managing infants on maintenance dialysis, an early transplant should be considered. Donors older than 24 months carry a low risk of vascular thrombosis and may be successfully grafted in infants.

De novo cancers in paediatric renal transplant recipients: a multicentre analysis within the North Italy Transplant programme (NITp), Italy

The purpose of this study was to determine the frequency and the outcome of de novo malignancies in a cohort of renal transplant paediatric patients. The records of 493 kidney transplants, carried out in 454 paediatric recipients at the three paediatric transplant centres of the North Italy Transplant programme (NITp, Italy) were reviewed. 10 cases of malignancies (2.2%) comprising both PTLD (post-transplant lymphoproliferative disorders) (6 cases, 1.3%) and non-PTLD malignancies (4 cases, 0.88%) were reported. Non-PTLD included one urothelial carcinoma and one Wilms' tumour of the recipient's left native kidney, one abdominal dysgerminoma and one optic nerve glioma of the left eye. The PTLD consisted of localised or disseminated Epstein-Barr virus (EBV)--associated B-lymphocyte monoclonal (5 cases) and polyclonal (1 case) proliferations. All patients suffering from PTLD had been EBV-negative at the time of transplantation, but developed EBV primary infection after transplantation. All PTLD patient donors were EBV-positive. In addition, all but 1 patient received, before and/or after transplantation, a range of immunosuppressive drugs in addition to the baseline prophylactic immunosuppressive regimen. Moreover, 3 patients suffered from syndromes associated with a genetic predisposition to cancer. Finally, the malignancies reported here were associated with 20% graft failure and 20% mortality rates.