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BACKGROUND: Kidney biopsy (KB) represents the criterion standard to obtain information on diagnosis and prognosis of renal allograft dysfunctions. However, it can be associated with bleeding complications (BCs). Bleeding time test (BTT), the best predictive indicator of post-biopsy BCs, is not a very reproducible test and is invasive. Therefore, the aim of this study was to evaluate whether the platelet function analyzer (PFA-100), a very reliable test to investigate primary hemostasis, could be useful in predicting the risk of bleeding complications in transplant patients undergoing KB. METHODS: We carried out a retrospective analysis of PFA-100 collagen-epinephrine (C-EPI) and collagen-adenosine diphosphate (C-ADP) closure times in 119 patients undergoing KB in our center. Data regarding BTT, age, sex, blood pressure, number of renal allograft punctures for each biopsy procedure, thromboplastin time, prothrombin time, complete blood count, and prophylactic therapy with desmopressin were also collected. Major (need for blood transfusion) or minor (no need for any intervention) BCs (hematoma and hematuria) were recorded. RESULTS: Indications for KB were: delayed graft function (n=23), allograft dysfunction (n=40), proteinuria (n=27), allograft dysfunction plus proteinuria (n=19), and protocol biopsy (n=10). Nine of the 119 patients (7.5%) developed minor BCs (6 macrohematuria, 3 hematoma), major BCs did not develop. No significant differences were found in any of the clinical and laboratory data, including BTT and PFA-100 (C-EPI and C-ADP) between patients who developed BCs compared with those who did not. In addition, there was no correlation between PFA-100 test (C-EPI and C-ADP) values and BTT data [R2=0.002; P=.6]. CONCLUSIONS: The PFA-100 test was not useful in predicting the risk of BCs in kidney transplant patients undergoing renal allograft biopsy.

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Atypical hemolytic uremic syndrome (aHUS), which can recur after renal transplantation, is associated with poor graft outcomes. The underlying genetic defect, namely, mutations in genes coding for the complement factor H, I (CFI), or membrane cofactor protein, greatly impacts the risk of aHUS recurrence. We report here the case of a patient with chronic renal failure due to aHUS in which screening for complement mutations, performed before wait-listing for kidney transplantation, showed a never described previously heterozygous mutation in the exon II of the CFI gene. Specifically, this mutation leads to a substitution of cytosine for guanosine at nucleotide 148, resulting in the change at amino acid 50 from arginine to proline. Subsequently, he received a renal allograft from deceased donor. Good graft function was established immediately, without clinical features of aHUS. Due to a lack of data on this mutation, we avoided prophylactic treatment for aHUS but closely monitored biochemical markers of aHUS to treat a possible recurrence. Immunosuppressive treatment was based on basiliximab, tacrolimus, steroids, and mycophenolic acid. At the time of discharge the serum creatinine was 1.4 mg/dL. Ten months after transplantation the patient is doing well without evidence of aHUS. Our case suggested that a heterozygous mutation in exon II of the CFI gene was not associated with a risk of early post-transplant aHUs recurrence adding new knowledge on complement mutations implicated in aHUS post-transplant recurrences.

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BACKGROUND: The use of central venous catheters for permanent vascular access has become increasingly important because of the characteristics and the clinical problems of incident patients or patients already undergoing chronic hemodialysis. In this study a short and medium term evaluation was made of a double permanent central venous catheter positioned in the right internal jugular vein. The Canaud catheter was evaluated both from the point of view of practical use and for various technical and clinical problems. METHODS: During the observation period, July 1995 - September 1999, these catheters were used in 39 patients (mean age 72 years), 22 females and 17 males; 31% were diabetic patients and 46% were older than 75 years. Forty-five catheters were positioned with an average dwelltime of 347 days. RESULTS: Utilization was almost immediate and the resulting blood flow was suitable for all depurative techniques (blood flow more than 250 ml/min), with an average recirculation of 11.9% and an average resistance index of 0.54. Among the most serious complications during surgery a respiratory block was observed followed by the complete recovery of the patient. Some clinical complications were noted (5 venous thrombosis), as were some technical ones: 12% well as related to problems with the adapter, 24.3% to reversible thrombosis of the catheters occurred in 23 catheters in 22 patients. Infections. CONCLUSIONS: Overall Canaud catheters appear to represent a valid alternative to other more recent catheters for permanent vascular access. If necessary, they can be easily substituted due to the absence of a subcutaneous cuff.

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BACKGROUND: Permanent central venous catheters for hemodialysis have become increasingly important as vascular accesses for extracorporeal dialysis. The aim of this study was to evaluate the prevalence and various aspects of these catheters in the chronic dialysis population in Piedmont and Aosta Valley on 30-6-1998 using a multiple-choice questionnaire. METHODS: A total of 2389 patients were receiving chronic hemodialysis. Permanent central venous catheters were present in 6.2% of the population (149 patients), arteriovenous fistulas in 83.1%, vascular prostheses in 9.3% and temporary catheters in 1.4%. The site chosen for permanent catheters was the internal jugular vein in 88.6% of cases, the subclavian vein in 8.7% of cases and the femoral vein in 2.7% of cases. The double catheter is the most frequently used. In 76% of centres catheters are positioned by nephrologists. Thrombosis prophylaxis is performed in 98% of cases with heparin and the most frequently used disinfectant to dress the cutaneous exit is iodopovidone. RESULTS: This study highlights the important role played by permanent catheters. The double catheter was used in 64.4% of the entire population, confirming the greater efficiency of these catheters as reported in the literature. Operating autonomy is relative in 76.2% of centres where catheters are positioned by nephrologists who often use the collaboration of other specialists. CONCLUSIONS: The authors stress the need to reflect on the use of iodopovidone is to dress the cutaneous exit of catheters since this disinfectant is contraindicated by one of the largest manufacturers of silicone catheters owing to its harmful medium long-term effects.

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BACKGROUND: A retrospective study was performed using a multiple-choice questionnaire in order to analyse the normal procedures and trends regarding the insertion and management of emergency dialysis access in patients with acute renal failure in 23 Centres in Piedment and the Aosta Valley, regions in the north of Italy with about 4.5 million inhabitants. METHODS: The observation period ran from January 1996 to July 1997. A questionnaire with 19 main questions and 90 possible multiple answers sent to 22 Centres for adults and the only pediatric centre in both regions. RESULTS: An analysis of the results showed that the most frequently used site in these regions is the subclavian vein (37.8%), followed by the internal jugular vein (32%), the femoral site (28.8%) and peritoneal catheter (1.4%); in pediatric patients, 5% used the femoral site, 10% the subclavian vein, 20% the internal jugular vein and 65% the peritoneal catheter. In 4 centres (18.2%), nephrologists do not position any type ofd access for acute renal failure. In 50% of centres, all doctors insert femoral catheters autonomously. CONCLUSIONS: Some choices, such as the subclavian route, are open to criticism and may perhaps be linked to customary procedures used by anesthetists and intensive care specialists. Some centres only have relative automomy for insertion, and lastly some types of catheters and techniques are not used. The peritoneal catheter has been abandoned by adult centres as an access in acute kidney failure patients.

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The use of alternative permanent vascular accesses has recently become increasingly common. The possibility of using the catheterization of central venous vessels has therefore been taken into consideration, in particular the internal jugular vein. During an observation period of 32 months the catheterization of the internal jugular vein (IJV) was used as a definitive access in 34 patients (12 M, 22 F; mean age 67.5, mean dialytic age 56 months in 18 patients, in 16 patients the insertion was by primary intention). A total of 44 IJV catheters were used, of which 18 Tesio and 26 Canaud. The authors examined the immediate complications following insertion and the episodes occurring during the observation period, including the problem of infection. The insertion of catheters was possible in all cases. In terms of catheter function, blood flow was adequate for the various purifying techniques. No severe complications were reported: gaseous embolism, pneumothorax, hemothorax, hemomediastinum. Infection was observed in 11 patients and 13 catheters, of which 70% were mainly provoked by Staphylococcus aureus and epidermidis. During the observation period there was a drop-out of 14 patients, 11 of whom died (3 following sepsis that failed to respond to antibiotic therapy). This preliminary experiment shows that permanent jugular catheters may be regarded as a valid access for hemodialytic treatment both in patients with severe problems of vascular access and for patients who present a short-term prognosis of dialysis and life expectancy at the time of starting hemodialysis.

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Standard heparin is still considered as a reference point for anticoagulation in CEC, although its use is not totally devoid of long-term and short term side effects, considering the risk of hemorrhage that patients undergo during dialysis. Numerous attempts have been made in the search for an alternative anticoagulating method. The recent discovery that low molecular weight fractions (LMWH) of standard heparin (UFH) assure the same antithrombotic effect but with a minor anticoagulating action, points to such a drug as an interesting alternative to the traditional use of heparin during dialysis. Our present task is to evaluate the purifying efficiency of different cuprophan and synthetic membranes with two LMWH and UFH, measuring the instantaneous ureic clearance of different dialysers at the start and end of each dialysis. N. 43 chronic patients were examined whilst undergoing different methods of treatment; using 12 different kinds of membrane, for a total of 22 filters. Every patient underwent a dialysis using each kind of heparin at least once, for a total of 189 dialysis. Neither the initial nor the final ureic clearances, nor the percentage of decreasing had changed by using different types of heparin and membranes with diverse thrombogenicity and ultrafiltration capacities. We may conclude from the results of the tests that the purifying efficiency of small molecules, judging from the istantaneous clearances, do not significant results compared to UFH.

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Atheroembolic disease is a complication of atheromatous disease and is quite often misunderstood. A precise diagnosis can be made difficult, by the lack of specific tests. The first case, in which we identified this disease, resulted from a bladder biopsy, in the instance of a patient with a suspected carcinoma. The experience, with this initial patient, led us to identification of a further 3 cases, within our previous 2 years case histories. One must consider the possibility of atheroembolic disease during the differential diagnosis of acute renal failure in geriatric patients, given the serious prognosis.

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The diagnostic tools used to achieve an assessment of allograft dysfunction should be as noninvasive as possible, because kidney graft recipients are fragile patients and quite often the need is for repeated investigations. In order to evaluate the reliability and accuracy of such a method, in this case scintigraphy with 99mTc-DTPA, the authors retrospectively studied 2 groups of kidney transplanted patients, having two different basic immunosuppressive regimens: group A--86 patients--taking steroids and azathioprine; group B--93 patients--taking steroids and cyclosporine. A total of 722 scans were retrospectively compared with scintigraphic information: 196 episodes of allograft dysfunction were due to acute rejection: 118 in group A, 78 in group B; 117 episodes were due to ATN: 75 in group A, 42 in group B; 11 episodes were ascribed to CyA acute nephrotoxicity. Group A and B behave differently in respect of the perfusion index. Only in group A were perfusion indexes statistically different in rejection, ATN and nephrotoxicity. Anyway, it must be stressed that, even if in group B, scintigraphy cannot be considered an accurate diagnostic method, it is somehow a helpful tool because it gives information about a worse perfusion of the graft, independently of the underlying pathology.

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The possibility of applying a once-a-week dialysis programme supplemented with hypoproteic diet as an adequate technique for starting the uraemic patient on dialysis is examined. Thirteen patients have been so treated, 7 of them currently under treatment for a global period of observation of 46 months. At the moment dialysis began, mean glomerular filtrate was 5.14 ml/min. Once-a-week dialytic treatment with bicarbonate dialysis was associated with a hypoproteic diet of 0.5 g/kg/die of proteins, supplemented with essential amino acids. This treatment showed excellent dialytic tolerance, the values of dialysis start blood nitrogen were lower than 200 mg/dl and dialytic efficiency was compatible with a Kt/v greater than 1.1. There was no observation of any subjective or objective symptomatology that could be related to dialytic inadequacy. Taken as a whole these results make it possible to state that this type of approach permits a gradual start to dialysis and deserves further study.

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The effect of early protein restriction (0.6 g:kg/p.i./die) in patients suffering from initial kidney failure for a period of two years has been studied. The hypoprotein diet proved effective in slowing development of kidney damage in so far as a stabilization was observed in renal function parameters during the hypoprotein diet period compared to the non-diet period.

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Abdominoperineal endoanal pull-through resection with colorectal anastomosis was performed on 728 patients--primarily those with chagasic megacolon and cancer of the rectum. Intestinal continuity was reestablished through immediate anastomosis (Swenson procedure) in 229 patients and through delayed anastomosis (Cutait-Turnbull procedure) in 499. Comparative studies showed: that the incidence of leakage was 31.9 percent in immediate and only 2.2 percent in delayed anastomosis; that presacral infection occurred in 27.9 percent in immediate and in 6.8 percent in delayed anastomosis; that stenosis was observed in 4.4 percent in immediate and 1.8 percent in delayed anastomosis; that mortality was 6.1 percent in immediate and 2.2 percent in delayed anastomosis; that anal continence was good in both procedures and that sexual disturbances were rare in benign and frequent in malignant lesions in both procedures. The final conclusion is that, in abdominoperineal endoanal pull-through resection with colorectal anastomosis, complications and mortality are less frequent in delayed than in immediate anastomosis and that continence and sexual behavior are identical in both procedures.

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Os autores relatam dois casos de rabdomiossarcoma pararretal, tumor mesenquinal maligno, de localizacao em musculos esqueleticos e em orgao que contem em sua estrutura tecido muscular estriado. No perineo, e em particular em situacao pararretal e raro sendo relatados na literatura apenas 12 casos. A molestia se manifestou sob a forma clinica de tumor inflamatorio e de tumor ulcerado pararretal sendo o exame, histopatologico de fragmentos colhidos por biopsia o elemento afirmativo do diagnostico. Os pacientes foram tratados por ciclos de quimico e radioterapia (1o. caso) e apenas quimioterapia (2o. caso). O primeiro teve excelente evolucao clinica e o segundo veio a falecer acometido por metastases osseas generalizadas.Os autores fazem uma analise dos trabalhos publicados sobre as manifestacoes clinicas os aspectos histopatologicos e sobre as condutas clinicas e cirurgica preconizadas Dentre as cirurgias a mais aceita e amputacao abdomino perineal do reto com eventual linfadenectomia regional. Atualmente com o advento de novas drogas e com o aperfeicoamento de tecnicas radioterapicas o tratamento quimico-radioterapico tem sido aconselhado

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