Please, sir, pull down your socks!

A 48-year-old male patient presented at the regular followupvisit seven months after a successful kidney transplant.After discussion of blood chemistries with the doctor, thepatient underwent a physical examination. As usual, heunbuttoned his shirt and undid his trouser belt. Inspectionof the limbs, after pulling up his trousers, confirmed thepresence of ankle oedema; the graft was quite firm, with nomurmurs in the area

Treatment of wounds colonized by multidrug resistant organisms in immune-compromised patients: a retrospective case series.

Immune-compromised patients incur a high risk of surgical wound dehiscence and colonization by multidrug resistant organisms. Common treatment has been debridement and spontaneous secondary healing.All immune-compromised patients referred to our Institution between March 1, 2010 and November 30, 2011 for dehiscent abdominal wounds growing multidrug resistant organisms were treated by serial wound debridements and negative pressure dressing. They were primarily closed, despite positive microbiological cultures, when clinical appearance was satisfactory.Nine patients were treated by direct wound closure, five had been treated previously by secondary intention healing.According to our results, fast healing can be safely obtained by closure of a clinically healthy wound, despite growth of multidrug resistant organisms, even in immune-compromised patients

Heparin and dialysis: reasons to make a change?

The availability of heparin was undoubtedly one of the main factors contributing to the widespread use of clinical dialysis: although lipolytic activity, osteoporosis and thrombocytopenia were described, clinical advantages remained unrivalled until today. Nevertheless, several effects attributable to heparin are less widely recognized, though theoretically noteworthy. Heparin has immunosuppressive properties, interfering with both humoral and cell-mediated immunity [1–2]: these actions should be probably taken in to account since dialysis patients are prone to infections and receive an average of 500000–1 million units/year of heparin. Heparin is able to split the activin–follistatin complex, allowing activin to stimulate smooth muscle cells of vessel wall to proliferate [3]; the risk of systemic atherosclerosis could therefore be increased [4]. In addition, by the same mechanism heparin could favour the process of intimal hyperplasia leading to stenosis, usually observed just at the venous end of vascular access, the site where dialysis-administered heparin concentration is higher than in any other site of the vessel system. Finally, the source of heparin could be of some concern after description of the variant of Creutzfeld-Jacob encephalopathy (vCJ) as a prion disease transmitted by cows suffering from BSE. Of interest, it was reported that there was an increased risk of sporadic CJD for patients undergoing surgery, unfortunately without explanation of the mechanism(s) involved [5]. Intra-operative or prophylactic post-operative heparin administration could not be ruled out. Since heparin can be extracted from beef or pork offal, beef-derived heparin should be re-evaluated for medical use and dialysis patients suffering from encephalopathies should be screened for vCJ. Apart from the more specific mode of action [6], recombinant hirudin should be considered if the safe origin of heparin cannot be certified

Management of vascular access for dialysis: an Italian survey.

No abstract available

L'organizzazione della chirurgia degli accessi vascolari: risultati di un questionario italiano

ABSTRACT: Vascular access surgery (VAS) plays a key role in the management of dialysis patients, but its organisation in ltaly remains largely unknown. Basing on a national survey, especially oriented to the management, and not to the clinical aspect of VAS, we describe some important points as regard to this activity. Differing from other countries, the nephrologist is the main manager o/VAS in Italy; the majority of dialysis centers (DC) monitor the performance of VA by means of different methods (but only 20% participate in a Continuous Quality lmprovement program. Central Venous Catheters (CVC) are largely utilised, both as permanent access and at the first dialysis session in chronic patients (aver 40% of patients in 25.4% of DC): it means that the planning of native access is very difficult and reveals unsolved problems in the management of the pool of chronic patients pool. Late referral still seems to be an obstacle to timely and optimal treatment of chronic renal failure. lnterventional radiology ( IR) is used by many DC, but only in 11.7% more than 1O procedures/year are performed. In conclusion, nephrologists directly manage VAS in ltaly, in differentiated ways that necessitate of well-defined guid elines. (Giorn lt Nefrol 1998; 15: 255-8)

Donor affected by hemosiderosis: is kidney transplantation possible? A case report

Marginal donors (advanced age, comorbidities, and so on) provide an increasing contribution to the kidneys used to alleviate the relative organ shortage. We describe the evaluation process and clinical outcome of two kidneys with hemosiderosis used as a double graft. The donor was a 59-year-old hypertensive man, known to have a mechanical mitral valve, who died from a cerebral hemorrhage, with a normal serum creatinine (SCr) and kidneys with normal appearances at sonography. A protocol donor biopsy showed a Karpinsky score of 5 for both kidneys. A double graft was therefore scheduled. The recipient was a 59-year-old man, on dialysis because of chronic glomerulonephritis. HLA match was incompatibility 4/6; immunosuppression was based on steroids, cyclosporine, and mycophenolate mofetil with basiliximab as induction therapy. The grafts showed delayed function with dialysis treatments performed from postoperative day (POD) 1. On POD 2, a magnetic resonance imaging (MRI) study showed the typical appearance of siderosis. Pearl's staining performed on a protocol biopsy confirmed the presence of widespread iron deposits. On POD 5, a recipient renal biopsy showed a superimposed severe acute tubular necrosis. Renal function recovered slowly; SCr at discharge on POD 22 was still 4.2 mg/dL. Two months later, the SCr was 2.2 mg/dL. A second MRI performed at 3 years and 6 months after transplantation confirmed a progressive removal of iron overload while the patient had stable renal function (glomerular filtration rate) of 33 mL/min and SCr: 2.3 mg/dL. We concluded that donors with hemosiderosis should be treated as marginal donors and may be grafted based on a pretransplant biopsy

Vascular access for haemodialysis: from surgical procedure to an integrated therapeutic approach.

During the past 10 years the type of vascular access for haemodialysis procedures have changed markedly in our centre: more elbow AV fistulae and more central venous catheters are now used. Nevertheless, early referral to nephrologists and availability of central venous catheters and peritoneal dialysis allow elderly people to be admitted for dialysis treatment. Since vascular access for haemodialysis plays a key role in patient well-being, it is mandatory to apply quality assurance criteria to vascular access for haemodialysis surgery. Based on the results of a national survey, in Italy this policy is still in its early stages: monitoring of vascular access differs amongst centres, interventional radiology is used in a differing way, planning of vascular access for haemodialysis in pre-dialysis patients often remains an unsolved problem. According to our initial experience, we propose the use and validation of a quality-index [(minimum success rate) in elective vascular access for haemodialysis surgery], allowing accreditation of a department and a single surgeon for access management. Prevalence of central venous catheters at first dialysis of chronic renal failure patients is also proposed to evaluate the efficiency in access planning. Better knowledge of vascular access management by different teams could eventually lead to definition of guidelines for this 'Cinderella of dialysis'