BACKGROUND:In the context of kidney transplantation (KT), multidisciplinary interventions, including assessment and management of psychosocial aspects, are important to improve transplant's outcome. The aim of this study was to describe a multidisciplinary team approach to KT, with a specific focus on early detection and treatment of psychological distress and psychopathologic conditions in the early phase postsurgery.METHODS:The multidisciplinary team in kidney transplantation was implemented in January 2016. In this team approach, all transplant recipients are invited to 3 scheduled appointments for a multidisciplinary evaluation at 1, 3, and 6 months posttransplant, including a psychiatric interview, with the aim to assess the patient's adjustment after transplantation and provide support when necessary.RESULTS:This pilot study involved all 41 KT recipients consecutively referred for the first multidisciplinary appointment after transplantation. Five subjects (12% of the study sample) presented with a current psychiatric diagnosis. Psychopharmacologic treatment was confirmed or introduced for all these patients. Further psychological support was suggested to 4 other patients (10%).CONCLUSION:KT significantly improves patients' quality of life. However, the percentage of subjects receiving psychopharmacologic treatment and referred for further psychological and psychiatric support (22%) suggests the need for careful monitoring of psychosocial aspects over the long term.

Background. Living donor kidney transplantation (LDKT) is the best therapy for patients with chronic renal failure. Its advantages, compared with cadaveric transplantation, include the possibility of avoiding dialysis, the likelihood of best outcome, and donor pool expansion. Careful assessment of potential donors is important to minimize the risks and ensure success. However, the proportion of donors disqualified has been poorly investigated. The aim of this work is to describe our experience and present the main reasons for missed donation. Methods. This was a single-center, retrospective study of all potential donors and recipients evaluated for LDKT between January 2008 and December 2017. Results. During the period of study, 81 donor-recipient pairs were evaluated. Of these, 45.7% were disqualified and 37 LDKTs were carried out. LDKT was the first choice in 68% of cases and preemptive in 20%; 60% of transplants were among family members. Sex distribution revealed a prevalence of females in the donor group (69%) and males in the recipient group (70%). The mean living donor age was 53 +/- 9.5 years; the mean recipient age was lower in recipients listed in the living transplant program than those listed for cadaver transplantation (45.8 +/- 13.4 vs 54.2 +/- 11.08; P<.0001). Reasons for denial included hypertension (18.9%), deceased donor transplant performed during the study period (16.2%), urologic pathology (13.5%), incompatibility (13.5%), withdrawal of consent by donor or recipient (13.5%), psychological unsuitability (8.1%), donor cancer (5.4%), and reduced renal clearance (2.7%). Conclusion. LDKT is considered an option especially for younger recipients. Of the potential kidney living donors, 45.7% were disqualified during the evaluation, with medical reasons being the primary cause.

Background. Kidney transplantation (KT) immunosuppression may induce bone tissue damage with bone mineral density (BMD) loss increasing bone fractures risk. Steroid therapy is considered the major player, but others factors are still under review.Patients and Methods. We designed an observational retrospective cohort study to evaluate bone damage after KT. The prevalence of osteopenia, osteoporosis, bone fractures, and the associated risk factors were investigated. The following parameters were recorded before transplantation and at the last follow-up: demographic indexes, cumulative steroid dose (CSD), dialytic and transplantologic age, previous nephropathy, femoral and lumbar BMD, fractures, immunosuppressors, calcemia, phosphoremia, rejection episodes, estimated glomerular filtration rate, and parathyroid hormone and vitamin D levels. Stata software (Stata Corporation, College Station, Texas, United States) was used for the statistical analysis, to perform the Fisher's exact test, Kruskal-Wallis test, Student t test, as well as univariate and multivariate analyses.Results. The analyzed cohort was composed of 297 patients (65.3% males and 34.7% females). Sixty percent of KT patients had normal BMD, 24% had osteopenia, and 15% had osteoporosis. Twelve percent were victims of bone fractures (8.4% minor, 2% femoral, and 1.7% vertebral). A significant correlation (P <.05) was observed for both osteopenia and osteoporosis with menopause, transplantologic age, CSD, previous glomerulonephritis, and mammalian target of rapamycin (mTOR) inhibitors treatment (imTOR).Conclusion. This study confirms the correlation between CSD (both before and after transplantation) and post -transplantation bone damage. It also shows that a large fraction of these patients had normal BMD related with a low steroid dose in our protocols. This correlation between imTOR assumption and osteoporosis deserves attention and warrants further in vitro analyses to be performed.

Background: Donation after circulatory death is an additional source to increase the donor pool. Italian DCD program started in the San Matteo general hospital in 2008 and it focused on Maastricht categories 2 and 4 and on a particular donor type called ECMO-prior to death. Methods: According to our hospital advanced resuscitation protocol a cardiopulmonary by-pass is performed in asystolic patients in order to allow brain perfusion while attempting to restore cardiac activity. Some of these patients die for irreversible cardiac or cerebral damage. If they meet donation criteria and family consent is obtained, they can be considered donors after circulatory death regardless of what criteria are used to certify death. These donors don't belong to any Maastricht categories because the extracorporeal circulation is performed only to save patient life, it is running at the moment of death diagnosis and it is maintained after death certification. To certify cardiac death the ecmo perfusion is stopped while a 20 minutes flat EKG is recorded and then it is restarted as abdominal (regional) perfusion. In other cases, when an electric cardiac activity (PEA) still remain, death is certified by means of standard neurological criteria and ECMO perfusion is maintained until organ retrieval. In our DCD protocol the kidney storage is performed in the pulsatile perfusion machine (RM3 -MP) for at least 8 hours.Organ viability is tested by an evaluation of the macroscopic appearance of the kidney, perfusion parametres and in particular renal resistance and histology. Results: Since september 2008 we have performed 14 successful transplantations from DCD among them 5 belong to ECMO prior to death. In the latter group the receiver of the very first DCD kidney developed Primary Non Function, the other ones show a good graft function at 4 years follow-up. Conclusions: Our experience shows that ECMO-prior-to death donors could be considered as good potential DCDs and their organs can be well preserved even after hours of ECMO. More donors will be recruited in Italy by patients undergoing ECMO

Introduction. Kidney transplantation represents the best therapeutic option for patients with end-stage renal disease (ESRD), providing the best outcomes for survival, quality of life, and cost-effectiveness. To increase kidney donations, in 2007, the Italian IRCCS Policlinico San Matteo Foundation in Pavia designed and conducted Programma Alba, a protocol for organ donation after cardiac death (DCD). This study evaluated the costs and health outcomes of DCD transplantation and in all types of transplants compared with current clinical practice.Patients and Methods. A Markov-based model was used to assess costs and health outcomes for new ESRD patients for 2008 to 2013. A health care founder perspective was used. Data sources were the Italian National Institute of Statistics and the Lombardy Registry of Dialysis and Transplantation. A microcosting analysis was performed to calculate costs related to clinical pathways for DCD. We assessed costs, survival, quality-adjusted survival, and cost-effectiveness.Findings. Changing the actual practice pattern for new patients with ESRD and increasing the availability of kidneys from DCD to 10 extra transplants per year will induce an incremental cost per quality-adjusted life-year of (sic)4255. Increases in transplantation to reach an extra 10% by transplant type would result in reduced costs and increased patient survival and quality of life compared with the current scenario.Interpretation. Our data show that increasing DCD transplants would result in a cost-effective policy to expand the kidney donor pool compared with current ESRD treatment patterns. Italian policies should make an effort to increase transplant rates to optimize cost-effectiveness in ESRD service supply.

Background Organ donation after circulatory death (DCD) has become an accepted strategy to reduce shortage of organs. The Italian legislation provides a mandatory 20-minute no-touch period after cardiac arrest before organ retrieval in Donor after Circulatory Death (DCD); for this reason doubts on viability of these organs discouraged Italian surgeons to perform DCD transplants. However, in 2008 we started the “Alba” DCD programme using the most performing tools for preservation of these organs including Extra Corporeal Membrane Oxygenation device (ECMO) and pulsatile machine perfusion (MP). Methods/Materials From 2008 we have had 26 procured donors for 52 kidneys. Among those we had 20 kidneys which were not retrieved and 32 were retrieved: 14 were subsequently transplanted and 18 discarded due to different causes. Initial experience using only ECMO at normothermia and cold storage (CS) leaded to a transplantation of 4 kidneys from 3 donors, and 2 of them are still functioning grafts. After the inclusion of machine perfusion (RM3 -MP), 10 kidneys were transplanted from 7 donors. Histology and cold ischemia time (15,7 h vs 15,9 h, NS), were similar between the CS and MP kidneys, although significantly the longer CIT reached 23 hours in MP group. Results Among the 4 CS kidneys, 2 showed Delayed Graft Function (DGF) and 1 Primary Non Function (PNF) and 1 graft loss due to renal vein thrombosis (IX p.o.d.), while in the MP group 3 showed an immediate graft function, 7 developed DGF but no PNF was observed; DGF time was significantly shorter in the MP group (9.7 vs 20.5 days, p<0.05). CS kidneys showed extremely difficult reperfusion in all cases when compared to MP kidneys. MP kidneys demonstrated better function (Serum-Creatinine mg/dl) at 1 month (2,5 ± 1,16 vs 4,4 ± 2,55 ) and improved at 3 months (1,65 ± 0,61 vs 3,2 ± 1,98). Among MP group 7 kidneys were discarded due to a high resistance. Conclusion DCD kidney transplantation is feasible even after a 20-minute no-touch period with the use of pulsatile machine perfusion, increasing the number of transplants with good graft function. MP gives us additional information of the quality of the organs that allows a more efficient use for transplantation.

Italian regulation requires 20 minutes of an isoelectric EKG registration after cardiac death,this raises issues on injury due to prolonged warm ischemia time (WIT) of DCD kidney. To address this,many procedures are adopted including ex vivo reconditioning on pulsatile Machine Perfusion (RM3TM-MP). Aim of this study was to evaluate the benefit of providing O2 to kidney during ex vivo reperfusion on post-ischemic recovery of graft function.The naturally respiratory pigment M101 (HEMO2Life®,HEMARINA SA)that releases O2passively,and which is effective at hypothermia,was added during MP;clinical and histological parameters were assessed after autologous KidneyTx.Methods:Landrace swine were randomized in experimental groups (N=4/group)as described in Table1.The model consists in a 75-min in situ WI followed by left kidney removal and a 10-hour hypothermic preservation period.Then, autologous Tx followed by contro-lateral nephrectomy was performed.Sacrifice was performed after 14 days.Endpoints were:kinetic of serum creatinine levels,histology samples.Table: No Caption available.Results: Values are expressed as mean±SD and analysed by Student's t-test. Creatinine values in MP + HEMO2Life®(Figure 1)were significantly lower compared to MP alone at day 6 (p=0.01) and compared to CS group at day 4 and day 5 (p=0.03 and 0.01), showing a faster recovery of kidney function.Despite these positive results, no major differences were found in histological features.Figure: No Caption available.Conclusions: Addition of HEMO2Life® in MP preservation significantly improved post-ischemic recovery of kidney function in a swine model of DCD.Deeper ultra-structural and biochemical analysis are underway in order to elucidate mechanisms of this protective effect. These preliminary data open new perspective on the benefit of HEMO2Life® in reconditioning of kidneys.

Although many variables may affect long-term graft survival no biomarker is available to identify donor kidney with poor quality and with inadequate short and long-term outcome. While in marginal donors pre-transplant renal biopsies are commonly performed to establish if donor kidneys are suitable for transplantation they are not performed in standard donors. In this study we assessed the relevance of pre-transplant morphological features on post-transplant renal function and evaluated the association between perioperative parameters with posttransplant histological and clinical findings. Kidney transplant recipients undergone pre-transplant and post transplant protocol biopsies at 1, 6, and 12 months were enrolled in the study. Perioperative and posttransplant clinical and biochemical parameters were recorded. Semiquantitative analysis of PAS stained kidney sections was used to determine the degree of lesions. Glomerular volume was measured by computed morphometry. A strong inverse correlation was found between donor age and renal graft function at 1, 6, and 12 months after transplantation. A prompt functional recovery was associated with a better renal function at 6 months and one year. Kidneys with higher glomerular volume demonstrated a lower serum creatinine at 1 month. Higher tubulo-interstitial grading at protocol biopsies was associated with a poor renal function at 1 month. Our findings confirm the importance of donor age in kidney transplant long-term outcome and demonstrate that pretransplant and protocol biopsies are valid options to determine graft outcome and to define therapeutic strategies and tailor immunosuppressive regimen for each patient.

For circulatory death Italian legislation provides that death declaration has to be performed only after irreversible cardiac arrest, i.e. by 20-minute flat electrocardiogram. This 20-minute no-touch period discouraged over the years Italian physicians to transplant organs from non-heart-beating donors/donation (NHBD). However, several experimental works demonstrated kidney viability even after 40-minute acirculatory warm ischemia. These results prompted the Pavia's transplantation group to establish the first NHBD programme in Italy: the “Programma Alba”. All details and related preliminary results have been recently published [1]. According to our experience on uncontrolled donors treated with post-mortem Extra Corporeal Membrane Oxygenation (ECMO) a category VI might be added to usually reported classification of NHBD/DCD (Donation after Cardiac/Circulatory Death). Description for such partially controlled category VI is: Death during ECMO maintenance [1]. In such case of organ donation death can be determined by brain [1,2] or cardiac/circulatory criteria according to ethical and legal frameworks. These donors are initially NHBD and, if neurological criteria are applied, become DBD (Donors after Brain-Death), i.e. organ perfusion has initially been absent and then ECMO maintained. These NHBD donor organs suffer from acirculatory warm ischemic insult due to different reasons: a) immediately after the initial cardiac arrest and before CPR if death is declared by neurological criteria; b) before CPR and during the no-touch period if cardiac criteria are used; c) in both cases organ perfusion may be suboptimal during the ECMO prolonged artificial circulation. If neurological criteria are used, organs might be considered like those from DBD/HBD (Heart-Beating Donor), but their perfusion is artificial as for uncontrolled DCD, eventually misleading the transplant team decisions. In Pavia 6 successful kidney transplants have been performed with 3 DCD and 2 DBD category VI non-heart-beating donors. Kidneys from ECMO-NHBD DBD donors suffered from a severe acute tubular necrosis similar to the damage caused by ischemia in Maastricht II and in ECMO-NHBD DCD donors. In conclusion, a simple but clinically relevant new classification of donors based on organ perfusion and including prior-to-death ECMO is proposed: Type I, when organ perfusion is natural even if supported by drugs; the type I category includes HBD/DBD. Type II, when cardiac/circulatory perfusion is absent or obtained by external artificial devices before organ retrieval. The type II category includes NHBD both DCD and DBD. To enhance information on the quality of the graft, two simple acronyms including all donation categories are suggested: 1) DDNP type I (Deceased Donor with Natural Perfusion) 2) DDAP type II (Deceased Donor with Artificial or Absent Perfusion).

Erythropoietin-stimulating agents (ESAs) are commonly used to treat anemia in kidney transplant recipients (KTRs). Since 2007, continuous erythropoietin receptor activator (CERA) has been one of the newest recombinant ESAs to treat anemia in dialysis and nondialysis patients with chronic kidney disease. The efficacy of CERA to manage anemia has not been extensively evaluated in KTRs. We evaluated safety, efficacy, and satisfaction among KTRs treated with CERA. We enrolled 19 anemic KTRs (60 ± 9.3 y) who were treated with short-acting ESA for ≥24 weeks. They were shifted to the equivalent dose of CERA and followed for 24 weeks. We measured serum hemoglobin, hematocrit, creatinine, iron, ferritin, and transferrin. To investigate tolerance to and satisfaction with short-acting ESA and CERA, questionnaires were administered to the patients before shifting to CERA and at the end of the follow-up. After 6 months, CERA induced an increase in hemoglobin levels (12.3 ± 0.8 vs 11.2 ± 1.1 g/dL; P = .002, CERA vs short-acting ESA, respectively). In 2 patients treatment was discontinued because the hemoglobin increased to >13 g/dL. No significant differences were observed in serum iron and creatinine between short-acting ESA and CERA throughout the study. The questionnaires showed better compliance to CERA treatment with reduced pain at the injection site, which led subjects to prefer CERA to short-acting ESA. In summary, CERA showed better control of anemia compared with short-acting ESA. It was preferred by the majority of patients, mainly because of the reduced number of monthly injections. Our results demonstrated CERA to be effective, safe, and well tolerated in the management of anemia in KTRs.

Transvaginal recovery of the kidney has recently been reported, in a donor who had previously undergone a hysterectomy, as a less-invasive approach to perform laparoscopic live-donor nephrectomy. Also, robotic-assisted laparoscopic kidney donation was suggested to enhance the surgeon's skills during renal dissection and to facilitate, in a different setting, the closure of the vaginal wall after a colpotomy. We report here the technique used for the first case of robotic-assisted laparoscopic live-donor nephrectomy with transvaginal extraction of the graft in a patient with the uterus in place. The procedure was carried out by a multidisciplinary team, including a gynecologist. Total operative time was 215 min with a robotic time of 95 min. Warm ischemia time was 3 min and 15 s. The kidney was pre-entrapped in a bag and extracted transvaginally. There was no intra- or postoperative complication. No infection was seen in the donor or in the recipient. The donor did not require postoperative analgesia and was discharged from the hospital 24 h after surgery. Our initial experience with the combination of robotic surgery and transvaginal extraction of the donated kidney appears to open a new opportunity to further minimize the trauma to selected donors.

La valutazione della storia naturale dell’infezione da HCV nei pazienti trapiantati di rene è complicata da alcune problematiche tra cui: la frequente asintomaticità dell’epatopatia; l’andamento delle transaminasi, espressione di danno epatocellulare, che sono fluttuanti e raramente elevati (1). Pertanto l’analisi istologica epatica rimane fondamentale per accertare l’entità delle alterazioni epatiche indotte da HCV (2). L’infezione da HCV sembra anche influenzare sia la sopravvivenza del paziente che del rene trapiantato, che negli studi a lungo termine, risultano essere più basse rispetto ai pazienti HCVnegativi, l’infezione rappresenta la causa di morte più frequente (3). Per tali ragioni è necessaria la messa a punto di protocolli specifici per definire le caratteristiche del candidato al trapianto renale con infezione da HCV. La biopsia epatica è indispensabile per accertare la severità del danno istologico epatico indotto da HCV nei pazienti con viremia (HCV Rna PCR) elevata, esame ormai essenziale per scrinare questa categoria di pazienti (2). Nei candidati con lesioni istologiche epatiche cirrotiche o pre-cirrotiche si consiglia di evitare il trapianto. Nei candidati con lesioni istologiche epatiche minime o con segni di epatite cronica (stadio I, II) e con documentata viremia HCV nel siero, va consigliata terapia antivirale. La limitata efficacia dell’Interferonnei pazienti trapiantati, associata all’elevato rischio di rigetto acuto e di effetti collaterali, suggerisce di trattare i pazienti dializzati con epatite cronica HCV correlata prima del trapianto (4). Le recenti evidenze suggeriscono che i pazienti uremici HCV+ con diagnosi istologica di epatopatia attiva dovrebbero essere sottoposti a trattamento antivirale specifico e protratto (Interferon+ ribavirina per 6-12 mesi) prima di valutare la possibilità di un trapianto renale (4). La nostra analisi retrospettiva ha lo scopo di valutare l’approccio clinico e la storia naturale dei pazienti HCV+ trapiantati di rene e in lista d’attesa afferenti al nostro Centro Trapianti.

Aims and Background Gastrinomas are the most common neuroendocrine tumors of the duodenopancreatic region. Surgical resection is the primary type of radical treatment. Methods and Study Design At the Institute of General, Gastrointestinal and Breast Surgery we treated a patient with a duodenal gastrinoma that was diagnosed and localized by means of selective celiacmesenteric angiography and labeled octreotide scintigraphy. Surgery was performed using a radioguided technique; in this way we easily detected the small tumor and discovered another tracer-uptaking lesion that turned out to be a metastatic lymph node. Results Surgical resection is the ideal treatment for sporadic gastrinoma: it improves quality of life, prolongs survival, and reduces the incidence of metastases, with a modest percentage of complications and practically zero mortality. Meanwhile, medical treatment is being revaluated, particulary in the case of metastatic disease or polyendocrine MEN1 syndrome. A fundamental aspect in the management of gastrinomas is tumor localization. Endoscopic ultrasonography and labeled octreotide scintigraphy (Octreoscan) proved to be more effective than the usual imaging modalities. Intraoperative ultrasonography, gastroscopy for duodenal transillumination and repeated measurement of blood gastrin levels should be performed intraoperatively in the surgical treatment of gastrinomas. Conclusions The clinical application of radioguided surgery for tracer-uptaking endocrine tumors is still controversial. In our case the decision to use this method was influenced by the fear that the patient's obesity and the effects of previous surgery could hamper the identification of the small tumor.

Visceral artery aneurysms are uncommon and usually result from atherosclerosis, periarteritis nodosa and fibromuscular dysplasia. Hepatic artery aneurysms were detected in two patient, splenic artery aneurysms in three. In four patients rupture occurred. In the two patients with hepatic artery aneurysm hemobilia from arterial rupture into the common bile duct and intraperitoneal bleeding in lesser sac was assessed. Ruptured aneurysms of the splenic artery with free intraperitoneal bleeding occurred in two patients, one patient had an asymptomatic splenic artery aneurysm. In four patients the diagnosis was made by contrast-TC and/or celiac and mesenteric angiography. In four patients excision of the aneurysm was successfully performed. One patient with ruptured hepatic artery aneurysm and in which resection and revascularization was made died.

PURPOSE:Restorative proctocolectomy is the procedure of choice in the treatment of ulcerative colitis. The operation is successful in removing all diseased mucosa while preserving a normal bowel function and a good quality of life for the patient. In this article are presented the clinical and functional results obtained in 28 patients, 19 males (68%) and 9 females (32%) after stapled restorative proctocolectomy with ileal J pouch-anal anastomosis.RESULTS:There were no perioperative deaths. The overall morbidity rate was 31%. Six patients (21%) presented pelvic abscess; 2 (7%) pelvic hematoma, 4 patients (14%) ileo-anal anastomotic stricture, 1 patient (3.6%) pouch-vagina fistula, three patients (11%) intestinal obstruction and 7 (25%) pouchitis. All patients were able to evacuate their pouches spontaneously. The mean bowel movements were 6-9/24 hours at the first postoperative month and 3-5/24 hours at the sixth month. Infrequent nocturnal seepage occurred in 6 patients (21%). Stool consistency returned to normal within 3-6 months. The mean pouch capacity was 210 cc. The mean resting pressure was diminished in 11 patients (39%), the men and maximal squeeze pressures were improved in 9 (32%); the ileo-rectal-anal inhibitory reflex was normal in 5 patients (18%), not defined in 12 (43%). Impotence or impaired bladder function was not present.CONCLUSION:The use of staplers in the surgical technique of restorative proctocolectomy with J shaped ileo-anal pouch is associated with low morbidity and better long-term results. The procedure requires a good selection of patients, a correct surgical timing, a very carefully technique and a low pre and postoperative treatment with steroids.

PURPOSE:Analysis of complications and causes of failure after stapled restorative proctocolectomy with ileal J pouchanal anastomosis in patients with ulcerative colitis is presented.PATIENTS AND METHODS:The procedure was performed in 28 patients, 19 males (68%) and 9 females (32%); diverting ileostomy was always performed.RESULTS:There was no perioperative mortality. The overall morbidity rate was 31%. Six patients (21%) had pelvic abscess, 2 (7%) pelvic hematoma, 4 patients (14%) presented ileo-anal anastomotic stricture, 1 patient (3.6%) had pouch-vaginal fistula, three patients (11%) presented intestinal obstruction and 7 (25%) pouchitis. Reoperation was necessary in patients with small bowel obstruction and with pouch-vaginal fistula. Septic complications and pouchitis were resolved with medical treatment. Stenosis of the anastomosis required anal dilation. No patient underwent pouch excision for pouch failure.CONCLUSION:The main significant complications of ileal pouch-anal anastomosis for ulcerative colitis were pelvic sepsis, intestinal obstruction and pouchitis. Our results suggest that the use of stapling technique is safer and has fewer early septic complications and sepsis-related pouch removals. Success in ileo-anal construction increases with experience. The selection of patients with exclusion of Crohn disease, a correct surgical timing, a carefully technique, a delayed ileostomy closure and a low pre and postoperative regimen of steroids are important factors of success.