G. Mosconi

Renal transplant in patients with polycystic disease: the Italian experience.

We analyzed the results of kidney transplantation in autosomal dominent polycystic kidney disease (ADPKD) patients in Italy, including 14,305 transplantations performed from January 2002 to December 2010, including: 12,859 first single or double kidneys from cadaveric donors (13% polycystic), 172 combined liver-kidney cases (22% polycystic), and 1,303 living-donor organs (7% polycystic). Among the first transplantations (12,008 single, 851 double), with follow-ups ranging from 16 to 120 months, polycystic patients demonstrated better graft survival compared with other kidney diseases (86% vs 82% at 5 years; P < .01); mortality was not different (92% vs 79% at 1 year). A better trend was obtained also among combined liver-kidney transplantations in ADPKD. Regarding pretransplantation management of polycystic patients, we noticed a conservative attitude in 32/35 transplant centers. The main indication for nephrectomy was for the lack of abdominal space. Regarding instrumental studies, 86% of centers asked for second-level investigations computerized tomography for kidney dimensions. Radiologic investigations for vasculocerebral malformations were required in 97% of the centers: 74% as a routine and 23% in the presence of familial history of cerebral hemorrhage. Polycystic patients are good candidates for kidney transplantation with correct management before transplantation.

Sport Activity and Health-Related Quality of Life After Kidney Transplantation

OBJECTIVEnConsidering the importance of sport activity for enhancing quality of life, the aim of this study was to investigate the effects of regular sport activity on quality of life of kidney transplant recipients.nnnMETHODSnHealth-related quality of life (HRQoL) was assessed with the use of the SF-36 questionnaire on a group of 118 active kidney transplant patients (AKTPs) practicing different sports at low to moderate intensity (5±4 h/wk). Scores were compared with those of 79 sedentary kidney transplant patients (SKTPs) and with 120 active healthy control subjects (AHCs).nnnRESULTSnAKTPs reported higher scores than SKTPs in the SF-36 scales of Physical Functioning (P<.05), Role Limitations due to Physical Problems (P<.05), General Health (P<.01), Vitality (P<.05), Social Functioning (P<.05), Role Limitations due to Emotional Problems (P<.05), and Mental Health (P<.01). AKTPs obtained higher scores than AHCs on the Mental Health (P<.01) and Social Functioning scales (P<.01) and similar scores (P>.05) on all the other scales. The effect of quantity of sport activity was significant on the General Health (P<.01; η2=0.05), and Role Physical scales (P=.04; η2=0.03), with higher sport activity associated with higher HRQoL. The effect of sex was significant for Bodily Pain (P=.05; η2=0.02), Vitality (P=.08; η2=0.06), Social Functioning (P=.08; η2=0.05), and Mental Health (P=.05; η2=0.02), with male participants scoring higher than female participants.nnnCONCLUSIONSnThis study indicates that regular sport activity significantly improves different dimensions of HRQoL among kidney transplant recipients. The benefits of sport activity go beyond its impact on physical health to involve psychologic and social components of quality of life. Spontaneous and low to moderate sport activity may play an important role after kidney transplantation that has been largely underestimated in the literature.

Physical Activity in Solid Organ Transplant Recipients: Organizational Aspects and Preliminary Results of the Italian Project

Most of the difficulties when trying to realize the proposal to prescribe physical activity for transplantation patients come from patient attitudes and cultural beliefs that ignore the benefits of exercise, but there also are organizational aspects arising from the difficulties that these patients face in accessing supervised exercise facilities. To address these difficulties, the Italian study project Transplant … and Now Sport was developed based on a model of cooperation among transplantation specialists, sports physicians, and exercise specialists organized as a team combining their specific skills to effectively actuate the physical exercise programs. This preliminary report is based on 26 patients (16 male, 10 female; 47.8±10.0 years old; 21 kidney and 5 liver transplantations; time from transplantation 2.3±1.4 years) who performed prescribed and supervised exercises consisting of 3 sessions per week of aerobic and strengthening exercises for 1 year. Preliminary results show a significant decrease in body mass index (t=1.966; P<.05) and a significant increase in peak aerobic power (t=4.535; P<.01) and maximum workload (t=4.665; P<.01) on the incremental cycling test. Also maximum strength of knee extensors (t=2.933; P<.05) and elbow flexors (t=2.450; P<.05) and countermovement jump performance (t=2.303; P<.05) significantly increased. Creatinine and proteinuria tended to decrease, but the differences were not significant. In health-related quality of life assessed by the SF-36 questionnaire, the Bodily Pain, General Health, Vitality, Social Functioning, and Role Emotional scale scores showed a significant improvement (P<.05). Preliminary results of the study protocol Transplant…and Now Sport show the positive effects of the model based on cooperation among transplantation centers, sports medicine centers, and gyms in the administration of a supervised exercise prescription. These data should be considered a contribution to developing and promoting further detailed exercise protocols and to fostering improved posttransplantation health and survival, helping to ensure that physical activity becomes a safe routine medical treatment plan of patient management.

Physical Activity in Solid Organ Transplant Recipients: Preliminary Results of the Italian Project

Background/Aims: The role of physical activity in transplanted patients is often underestimated. We discuss the Italian National Transplant Centre experience, which started in 2008 studying transplanted patients involved in sports activities. The study was then developed through a model of cooperation between surgeons, sports physicians and exercise specialists. Methods: A multicentre study was realized in 120 transplanted patients of which 60 treated with supervised physical activity (three sessions/week of aerobic and strengthening exercises) and 60 controls. We present the results of the first 26 patients (16 males, 10 females; 47.8±10.0 years; 21 kidney, 5 liver transplanted; time from transplant 2.3±1.4 years) who completed 12 months of supervised physical activity. Results: Data showed an increase of peak aerobic power (t=4.535; P<0.01) and maximum workload (t=4.665; P<0.01) in the incremental cycling test. Maximum strength of knee extensors (t=2.933; P<0.05) and elbow flexors (t=2.450; P<0.05), and the power of lower limb (t=2.303; P<0.05) significantly increases. Health Related Quality of Life showed a significant improvement. Serum creatinine (1.4±0.5 vs 1.3±0.4 mg/dL) and proteinuria (0.10±0.14 vs 0.08±0.08 gr/dL) were stable. Conclusion: These preliminary results confirm the positive effects of supervised physical exercise. It can be considered as an input to promote other detailed exercise protocols.

Alpine Skiing and Anaerobic Performance in Solid Organ Transplant Recipients

Limited information has been published about sporting activities in solid organ transplant recipients. The aim of this study was to assess in the field performance capacities of a group of transplant recipients involved in an alpine skiing competition. We studied 16 transplant recipients (13 men and 3 women) who had undergone transplantations (11 kidney, 4 liver, and 1 heart) at 89 +/- 68 months prior while participating in an alpine skiing race. The patients performed a countermovement jumping test to measure the explosive power of the lower limbs. In all patients blood lactate concentrations (La) were measured at the end of a giant slalom race. The maximum displacement of the center of mass during the jumping test was 22.4 +/- 9.3 cm; the time to complete the giant slalom was 75.5 +/- 16.5 seconds and La was 3.5 +/- 0.8 mmol/L. We observed significant linear relationships between race time and La (R(2) = 0.4733; P < .01) and between race time and performance in the jumping test (R(2) = 0.3655; P < .05). This study indicated that recovery of anaerobic and technical sporting activities is possible in organ transplant recipients. Muscular power and anaerobic performances among a selected group of solid organ transplant recipients were similar to those of the general untrained population.

Inflammatory and Adipose Response in Solid Organ Transplant Recipients After a Marathon Cycling Race

BACKGROUNDnOrgan transplant recipients frequently have chronic inflammation, with axa0weighty impact on cardiovascular risk. These patients can benefit from exercise, although the role of intense training is unclear. We evaluated the effect of a 130-km cycling race on inflammatory cytokines and adiponectin levels in transplant recipients.nnnMETHODSnCirculating interleukin (IL)-6, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, and adiponectin were assayed in 35 healthy subjects vs 19 transplant recipients (10xa0kidney, 8 liver, 1 heart), matched for sex, age, body mass index, and preparation workout. The determinations were performed before the race, at the end, and after 18 to 24 hours. Baseline values of 32 sedentary transplant recipients also were evaluated toxa0explore the possible chronic impact of lifestyle.nnnRESULTSnAll cyclists had 6- to 8-fold increased IL-6 levels after the race that decreased, without returning to baseline, the day after. Conversely, serum TNF-α and IFN-γ showed a progressive increase starting during physical performance and enduring for the next 18 to 24 hours in healthy subjects, whereas they were unchanged over time in cyclists with transplants. In transplant recipients who did not perform exercise, all of the analytes were significantly higher in comparison to basal levels of physically active subjects.nnnCONCLUSIONSnOur data suggest that clinically stable and properly trained transplant recipients can safely perform and progressively benefit from exercise, even at a competitive level. The changes in inflammation parameters were temporary and parallel with those of the healthy subjects. The comparison with sedentary transplant recipients revealed an overall amelioration of inflammatory indexes as a possible effect of regular physical activity on systemic inflammation.

Trapianto di rene in pazienti con patologia policistica: valutazione pre-trapianto e risultati. Esperienza italiana

aneurismatiche (intracraniche, aortiche, polmonari, spleniche, pancreatiche), a difetti valvolari cardiaci, a diverticolosi del colon, a ernie addominali o inguinali, ad ectasia biliare. I pazienti con rene policistico, nonostante le manifestazioni extrarenali correlate, hanno una sopravvivenza in dialisi maggiore rispetto ai pazienti affetti da insufficienza renale terminale da altre cause (6, 7). Anche relativamente a programmi di trapianto i risultati riportati in letteratura risultano mediamente superiori a quelli che si riscontrano in altre patologie renali (nefropatie glomerulari o vascolari). Il potenziale coinvolgimento di altri organi richiede una particolare attenzione nella fase di studio per programmi di trapianto. Spesso si registrano atteggiamenti diversi tra i vari Centri Trapianto per quanto riguarda gli aspetti chirurgici (indicazione alla nefrectomia) e la tipologia di indagini strumentali aggiuntive (per esempio, studio vascolare cerebrale); la proposta di percorsi differenziati per l’inserimento operativo in lista può ingenerare difficoltà di gestione da parte dei Centri Dialisi che hanno in carico i pazienti. Anche in letteratura, peraltro, si evince un’ampia eterogeneità di comportamenti. Al fine di individuare alcuni punti di riferimento lo studio si è proposto di verificare l’atteggiamento dei diversi Centri Trapianto Italiani relativamente alla gestione dei pazienti policistici candidati al trapianto sia dal punto di vista chirurgico (nefrectomia) che diagnostico/ strumentale (indagini al momento dell’inserimento in lista e nel successivo follow-up). È stato inoltre verificato, in collaborazione con il Centro Nazionale Trapianti, l’impatto della patologia policistica sui programmi di trapianto e i relativi risultati a breve, medio e lungo termine. Introduzione

Schemi di terapia immunosoppressiva e livelli ematici consigliati

I regimi immunosoppressivi standard consistono nella somministrazione di un solo farmaco, di solito un inibitore della calcineurina (CNI), seppure nei pazienti trapiantati prima degli anni Ottanta è possibile riscontrare anche l’azatioprina, associata allo steroide (Schema Duplice); oppure di due immunosoppressori a differente meccanismo d’azione, di solito un CNI con un inibitore della sintesi del DNA o un inibitore della sintesi di mTOR, sempre in associazione con lo steroide (Schema Triplice). Nel corso degli anni si osserva che lo Schema Duplice è sempre meno utilizzato e viene riservato a quei soggetti che sviluppano “intolleranza” all’immunosoppressore di accompagnamento (3) (Tab. I).