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Infections are an important cause of morbidity and mortality during kidney transplant. In areas where tuberculosis is not endemic, Mycobacteria other than tuberculosis (MOOT), also known as 'atypical' Mycobacteria, are more frequently involved in mycobacterial infections than M. tuberculosis. The incidence of MOOT infection in renal transplant recipients ranges from 0.16 to 0.38 percent. This low rate of reported incidence is, however, often due to delay in diagnosis and lack of therapeutic protocols. Further difficulty is caused by the interaction of antimycobacterial drugs with the post-transplant immunosuppressive regimen, necessitating close monitoring of plasma concentrations and careful dose modification. We present two cases of Mycobacterium Chelonae infection in kidney transplant recipients which differ in both clinical presentation and pharmacological approach.

Hyperphosphatemia is pivotal in some complications secondary to kidney dysfunction. Current guidelines suggest that hyperphosphatemia due to kidney dysfunction develops only when kidney function is reduced to <50%. This paper deals with the relationship of age to phosphatemia and with the possible influences of this relationship on hyperphosphatemia due to kidney dysfunction. In pediatric age phosphatemia decreases during growth. A recent epidemiological study showed a decrease in phosphatemia with age among adults also. This decrease differs between men and women, being continuous in men but not women because of a transitory increase in phosphatemia during menopause. Data also show that age-associated differences in phosphatemia among adults are explained by differences in the maximum reabsorption of phosphate in the renal proximal tubule (TmP/GFR). Other studies suggest that the opposite influences on TmP/GFR of growth hormone (stimulation) and estrogens (inhibition) are the determinants of the changes in TmP/GFR and phosphatemia associated with age. The inverse relationship of age with phosphatemia leads to the hypothesis that, in the presence of a disorder increasing phosphatemia, the prevalence of hyperphosphatemia would be higher in young adults than in elderly people, who have lower phosphatemia in health. A large clinical study supports this hypothesis, showing that hyperphosphatemia secondary to kidney dysfunction is approximately four times higher at age <65 than at age >65 years. Data suggest that the relation between kidney function and phosphatemia should be re-evaluated considering possible confounding due to age.

There has been a progressive increase in the number of intensive care patients being transferred to nephrology units because of improper dosage of drugs, especially patients with chronic kidney disease (CKD). Voriconazole is a new synthetic triazole derivative with stronger therapeutic activity against fungal infections than fluconazole or itraconazole. Its effectiveness is associated with high nephrotoxicity, affecting patients with CKD in particular. The adverse effects of voriconazole involve several segments of the nephron, particularly the proximal tubule, medullary thick ascending limb, and collecting duct, causing loss of potassium and magnesium and backdiffusion of hydrogen ions. We report the case of an 86-year-old man with moderate CKD who developed acute renal failure as a result of inadequate dosage of voriconazole. He developed oliguria, electrolyte imbalance and fluid overload requiring hemodialysis. Vericonazole withdrawal associated with short daily hemodialysis treatment led to the recovery of diuresis, kidney function, and electrolyte balance. In conclusion, in elderly patients with liver disease and moderate CKD, thorough evaluation is needed before the administration of voriconazole in order to establish the most appropriate dose.

The evaluation of urinary albumin excretion (UAE) and estimated glomerular filtration rate (eGFR) is suggested for the assessment of cardiovascular risk. It is unclear whether UAE and eGFR provide complementary information. UAE, eGFR, cardiovascular risk factors, and the incidence of cardiovascular disease were analyzed in 45- to 64-year-old individuals involved in the Gubbio study. UAE in the highest decile was defined as high (microng/min: > or = 18.6 in men and > or = 15.7 in women), eGFR in the lowest decile as low (mL/min/1.73 m(2): <64.2 in men and <57.9 in women). Kidney dysfunction was more frequent when defined by both markers than when defined by one marker only (UAE or eGFR) because high UAE and low eGFR tended to cluster in different individuals. The hazard ratio (HR) for incident cardiovascular disease was 1.85 in individuals with high UAE only (95%CI 1.04-3.25), 1.84 in individuals with low eGFR only (95%CI 1.04-3.26), and 5.93 in individuals with high UAE and low eGFR (95%CI 2.58-13.61). Concomitant evaluation of UAE and eGFR should be considered to adequately assess kidney dysfunction and cardiovascular risk.

We need a new health care system that is based on patients' needs. The present cadre of health managers who acquired power by cutting expenditures must be removed from office. We need to educate a new cadre of health managers who are 1) convinced that safeguarding health does not use up the resources of the next generations; 2) capable of switching the system from curative to preventive medicine; and 3) able to reinforce clinical research. Such principles have been recently adopted by the French President Sarkozy in devising the national health care program.

Estimated glomerular filtration rate (eGFR) and urinary albumin (U-Alb) have been suggested as indicators for the early identification of persons with kidney dysfunction. The Gubbio Study collected data on serum creatinine, UAlb, other laboratory indices, blood pressure, and medical history in a population sample of 4574 adults (2083 men and 2491 women, age range 18- 95 years). The study included analyses on six disorders which are commonly associated with kidney disease (hypertension, cardiovascular disease, anemia, high serum uric acid, high serum phosphorus/low serum calcium, and high serum potassium). Low eGFR (<60 mL/min per 1.73 m2) was found in 6.6% of men and 6.2% of women. Low eGFR prevalence varied largely with age (from <1% at 18-24 years up to > 30% at > or =75 years in both sexes, p<0.001). On the basis of these data, it was estimated that the prevalence of low eGFR in the whole Italian population could be 1.3 million among men (95%CI 1.1/1.5) and 1.5 million among women (95%CI 1.3/1.8). Data available only for age 45-64 indicate that 6.4% of men and 3.0% of women have high U-Alb (> or =20 microg/min) in the presence of non-low eGFR. Low eGFR was associated with at least two disorders potentially due to kidney disease in the majority of persons but was rarely associated with a previous diagnosis of kidney disease (<5% of cases). These data support the use of eGFR for the screening of people with or at risk of developing kidney disease. Awareness of kidney disease is very low in the Italian population.

The moderate elevation in urinary albumin excretion defined as microalbuminuria is common in the population and associated with cardiovascular (CV) risk factors. Microalbuminuria prevalence is low in the absence of CV risk factors and progressively increases with the number of the individual's CV risk factors. The main correlate of microalbuminuria is blood pressure (BP). The relationship between BP and microalbuminuria is continuous and graded since the prevalence of microalbuminuria increases with the severity of hypertension. Among hypertensives receiving treatment, BP control is associated with a low prevalence of microalbuminuria. Therefore, BP appears as a determinant of microalbuminuria rather than a mere correlate. For hypercholesterolemia, smoking and diabetes, the data are less strong, but point to an independent positive association with microalbuminuria. Altogether, data indicate that microalbuminuria in the population reflects the presence of CV risk factors. Data concerning microalbuminuria and coronary heart disease (CHD) support this idea. There is a continuous and graded relationship between urinary albumin excretion and CHD prevalence. High urinary albumin excretion is a likely sign of vascular damage existing both at renal and cardiac levels and induced by one or more uncontrolled CV risk factors.