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OBJECTIVE: The purpose of the study was to evaluate the exercise tolerance and the behaviour of blood pressure during a maximal exercise testing on treadmill for a group of patients with renal transplant carried out at least 6 months earlier. EXPERIMENTAL DESIGN, SETTING AND PATIENTS: In a retrospective study, nineteen patients were examined in our laboratory: 13 boys and 6 girls, mean age 15.8 years (range 10.5-22). INTERVENTIONS: All patients were given a clinical examination, an ECG at rest, a maximal exercise testing on treadmill (Bruce protocol), a mono-2D echo, a lung function test and 24-hour Holter monitoring. The results of the exercise test were compared with those of two control groups of same age and body surface area. RESULTS: The clinical examination of their cardiovascular apparatus gave normal results. The echo revealed anatomical and heart function anomalies related to the original disease. Exercise testing on treadmill showed a reduction in exercise tolerance (p < 0.001) and the maximal heart rate showed a statistically significant difference (p < 0.001) in comparison to control groups. Maximal systolic blood pressure was higher than in patients with same body surface area (p < 0.001) and higher than in peers (p = 0.133). CONCLUSIONS: In view of this hypertensive response, strenuous physical activity should be undertaken with caution and indeed submaximal aerobic activity is more suitable for this population of patients. [ABSTRACT FROM AUTHOR]

Background: Although it is well established that students' adaptive reactions towards errors promote learning outcomes, little is still known about the role of error feedback in promoting these reactions., Aim: Through a targeted intervention based on an online teaching unit, this study aimed at testing whether supportive error feedback promotes more adaptive students' reactions towards errors and higher learning outcomes., Sample: A total of 250 (M age   = 12.18, SD = .89; 46.4% girls) Italian middle school students took part in the intervention. Students were randomly assigned to either a discouraging error feedback condition (n  = 124) or a supportive error feedback condition (n  = 126)., Method: The intervention consisted of an online teaching unit, which students filled in at home, that was divided into pre-test, intervention and post-test phases. During the intervention, students replied to training questions and every time they made an error, informative feedback appeared: supportive smileys and sentences in the supportive feedback condition, and disappointed smileys and sentences in the discouraging feedback condition. Before the intervention, students filled in the pre-test and after the intervention, students reported their reactions towards errors and filled in the post-test., Results: Receiving supportive feedback resulted in more adaptive affective-motivational reactions towards errors, which in turn were related to more adaptive action reactions towards errors. Differently from our expectations, action reactions towards errors were not related to the post-test scores., Conclusions: Our findings can inform the development of online teaching units that promote an error-oriented approach., (© 2024 British Psychological Society.)

It is now well documented that school closures enforced at the beginning of the COVID-19 pandemic impaired teachers' well-being. Yet, only a few studies tracked changes in teachers' well-being during the subsequent phases of the pandemic, phases that were characterized by the discontinuous implementation of in-person teaching and distance learning. To fill this gap, we conducted a follow-up study at the end of the school year 2020-2021 (May-June 2021, T2), administering an online questionnaire to Italian teachers ( N = 240) who had previously taken part in a data collection conducted at the end of the first school closures (May-June 2020, T1). Our first aim was to monitor changes in teachers' psychological and work-related well-being between T1 and T2. Our second aim was to assess whether time spent on distance learning moderates these changes in psychological and work-related well-being. Results showed that teachers' psychological well-being decreased between T1 and T2, whereas work-related well-being increased. What is more, time spent on distance learning moderated the general increase in work-related well-being observed at T2: The longer teachers implemented distance learning during the school year 2021, the less their work-related well-being increased. In conclusion, although it seems that teachers have adapted to the changes associated with the first school closures, this study showed that distance learning remains a possible risk factor for teachers' well-being. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

In the context of the Coronavirus disease (COVID-19) outbreak, teachers faced unprecedented challenges and threats while implementing distance learning. Consequently, teachers may have experienced emotional exhaustion. The aim of our study was threefold: To explore teachers' threat appraisals, to investigate the relation between teachers' threat appraisals and their emotional exhaustion, and to examine processes protecting teachers from emotional exhaustion. Self-efficacy belief, especially, may have driven teachers' perceptions of distance learning as an opportunity (i.e., distance learning strengths), rather than an impediment (i.e., distance learning weakness) to teaching. During the first wave of COVID-19, Italian teachers (N = 1,036) filled in an online survey. A mixed-method design was used to address our three research aims. Findings indicated that, above and beyond other COVID-19 threats, one third of teachers reported worries, fears, and concerns related to their job (i.e., job-related threats). Furthermore, those who mentioned job-related threats experienced greater emotional exhaustion. Finally, teachers' self-efficacy was related to lower emotional exhaustion both directly and indirectly via teachers' perceptions of distance learning. Indeed, distance learning weaknesses (but not distance learning strengths) mediated the negative relationship between self-efficacy and emotional exhaustion. Altogether, our findings encourage reflection on possible interventions to reduce teachers' job-related threats and help them navigate distance learning effectively. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: Despite an internationally recognized significant increase of students with a diagnosed Specific Learning Disorder (SLD) entering higher education, psychological features of university students with SLD still remain to be explored., Aims: The study aims to investigate the perceived academic self-efficacy and to identify predictors of psychological well-being in a sample of university students with SLD, compared to a control group of students without SLD., Methods and Procedure: 60 Italian undergraduate students with SLD and 283 students without SLD were included in this study., Outcomes and Results: Results indicated that university students with SLD, compared to students without SLD but with comparable academic achievement, did not report significantly lower levels of academic self-efficacy. Furthermore, a multiple regression analysis indicated that self-esteem and perceived social support by significant others did significantly predict the value of psychological well-being in students with SLD., Conclusions and Implications: The findings suggest that undergraduate students with SLD may represent a particular category of young adults who have beaten the odds, who have persisted in effort even if they struggled and then who have succeeded., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Children with chronic kidney disease suffer from excessive cardiovascular mortality and early alterations of the cardiovascular system. Tissue doppler imaging is a validated echocardiographic tool to assess early systolic and diastolic cardiac dysfunction. We hypothesized that tissue Doppler velocities would reveal reduced cardiac function in children with chronic kidney disease compared to healthy children. A standardized echocardiographic exam was performed in 128 patients of the Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) Study aged 6-17 years with an estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m 2 . Tissue Doppler measurements included early (E') and late (A') diastolic and systolic (S') velocity at the mitral and septal annulus of the left ventricle. Measured values were normalized to z-scores using published reference data. Predictors of E'/A', E/E', S' and left ventricular mass index (LVMI) were assessed by multiple linear regression analyses. Tissue Doppler E' was reduced and tissue Doppler A' increased, resulting in a reduced tissue Doppler E'/A' ratio (z-score -0.14, p < 0.0001) indicating reduced diastolic function compared to healthy children. Reduced tissue Doppler E'/A' Z-Scores were independently associated with lower eGFR (p = 0.002) and increased systolic blood pressure (p = 0.02). While E/E' Z-Scores were increased (Z-score 0.57, p < 0.0001), patients treated with pharmacological RAS blockade but not with other antihypertensive treatments had significantly lower E/E' and higher E'/A' Z-Scores. Systolic tissue Doppler velocities were significantly decreased (Z-score -0.24, p = 0.001) and inversely correlated with E/E' Z-Scores (r = -0.41, p < 0.0001). LVMI was not associated with systolic or diastolic tissue Doppler velocities. Concentric left ventricular hypertrophy showed a tendency to lower S' in multivariate analysis (p = 0.13) but no association to diastolic function. Concentric left ventricular geometry was significantly associated with lower midwall fractional shortening. In summary, systolic and diastolic function assessed by tissue Doppler is impaired. eGFR, systolic blood pressure and the type of antihypertensive medications are significant predictors of diastolic function in children with CKD. Left ventricular morphology is largely independent of tissue Doppler velocities. Tissue Doppler velocities provide sensitive information about early left ventricular dysfunction in this population.

Background: Literature suggests that Specific Learning Disorders (SpLD) can cause impairment of Health-Related Quality of Life (HRQoL) and psychological well-being of children, and that this condition potentially affects parents' quality of life and well-being too., Aims: This study aims first to explore HRQoL and psychological well-being among children with SpLD and second among mothers of children with SpLD., Methods and Procedures: Thirty children aged 8-14 years diagnosed as having SpLD and their mothers completed a battery of scales to assess children's HRQoL and psychological well-being. Mothers also completed a battery of instruments to explore their personal HRQoL and psychological well-being., Results: Compared with the general population, children with SpLD reported significantly lower level of psychosocial health, and mothers had a higher probability of being anxious and/or depressed., Conclusions and Implications: This study supports previous research about impaired HRQoL, symptoms of generalized anxiety, school-related anxiety and depressed mood in children with SpLD. Moreover, it provides evidence that mothers of children with SpLD may experience stress in coping with their child's disability and develop socio-emotional symptoms such as anxiety. Implications concern the need to implement effective supportive services among children with SpLD and their parents., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The early impact of renal transplantation on subclinical cardiovascular measures in pediatric patients has not been widely investigated. This analysis is performed for pediatric patients participating in the prospective cardiovascular comorbidity in children with chronic kidney disease study and focuses on the early effects of renal replacement therapy (RRT) modality on cardiovascular comorbidity in patients receiving a preemptive transplant or started on dialysis., Methods: We compared measures indicating subclinical cardiovascular organ damage (aortal pulse wave velocity, carotid intima media thickness, left ventricular mass index) and evaluated cardiovascular risk factors in 166 pediatric patients before and 6 to 18 months after start of RRT (n = 76 transplantation, n = 90 dialysis)., Results: RRT modality had a significant impact on the change in arterial structure and function: compared to dialysis treatment, transplantation was independently associated with decreases in pulse wave velocity (ß = -0.67; P < 0.001) and intima media thickness (ß = -0.40; P = 0.008). Independent of RRT modality, an increase in pulse wave velocity was associated with an increase in diastolic blood pressure (ß = 0.31; P < 0.001). Increasing intima media thickness was associated with a larger increase in body mass index (ß = 0.26; P = 0.003) and the use of antihypertensive agents after RRT (ß = 0.41; P = 0.007). Changes in left ventricular mass index were associated with changes in systolic blood pressure (ß = 1.47; P = 0.01)., Conclusions: In comparison with initiating dialysis, preemptive transplantation prevented further deterioration of the subclinical vascular organ damage early after transplantation. Classic cardiovascular risk factors, such as hypertension and obesity are of major importance for the development of cardiovascular organ damage after renal transplantation.

Importance: Conventional methods to diagnose and monitor chronic kidney disease (CKD) in children, such as creatinine level and cystatin C-derived estimated glomerular filtration rate (eGFR) and assessment of proteinuria in spot or timed urine samples, are of limited value in identifying patients at risk of progressive kidney function loss. Serum soluble urokinase receptor (suPAR) levels strongly predict incident CKD stage 3 in adults., Objective: To determine whether elevated suPAR levels are associated with renal disease progression in children with CKD., Design, Setting, and Participants: Post hoc analysis of 2 prospectively followed up pediatric CKD cohorts, ie, the ESCAPE Trial (1999-2007) and the 4C Study (2010-2016), with serum suPAR level measured at enrollment and longitudinal eGFR measured prospectively. In the 2 trials, a total of 898 children were observed at 30 (ESCAPE Trial; n = 256) and 55 (4C Study; n = 642) tertiary care hospitals in 13 European countries. Renal diagnoses included congenital anomalies of the kidneys and urinary tract (n = 637 [70.9%]), tubulointerstitial nephropathies (n = 92 [10.2%]), glomerulopathies (n = 69 [7.7%]), postischemic CKD (n = 42 [4.7%]), and other CKD (n = 58 [6.5%]). Total follow-up duration was up to 7.9 years, and median follow-up was 3.1 years. Analyses were conducted from October 2016 to December 2016., Exposures: Serum suPAR level was measured at enrollment, and eGFR was measured every 2 months in the ESCAPE Trial and every 6 months in the 4C Study. The primary end point of CKD progression was a composite of 50% eGFR loss, eGFR less than 10 mL/min/1.73 m2, or initiation of renal replacement therapy., Main Outcomes and Measures: The primary end point in this study was renal survival, defined as a composite of 50% loss of GFR that persisted for at least 1 month, the start of renal replacement therapy, or an eGFR less than 10 mL/min/1.73 m2., Results: Of the 898 included children, 560 (62.4%) were male, and the mean (SD) patient age at enrollment was 11.9 (3.5) years. The mean (SD) eGFR was 34 (16) mL/min/1.73 m2. The 5-year end point-free renal survival was 64.5% (95% CI, 57.4-71.7) in children with suPAR levels in the lowest quartile compared with 35.9% (95% CI, 28.7-43.0) in those in the highest quartile (P < .001). By multivariable analysis, the risk of attaining the end point was higher in children with glomerulopathies and increased with age, blood pressure, proteinuria, and lower eGFR at baseline. In patients with baseline eGFR greater than 40 mL/min/1.73 m2, higher log-transformed suPAR levels were associated with a higher risk of CKD progression after adjustment for traditional risk factors (hazard ratio, 5.12; 95% CI, 1.56-16.7; P = .007)., Conclusions and Relevance: Patients with high suPAR levels were more likely to have progression of their kidney disease. Further studies should determine whether suPAR levels can identify children at risk for future CKD.

The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.

Objective: To determine a simplified method to identify presence of left ventricular hypertrophy (LVH) in pediatric populations because the relationship between heart growth and body growth in children has made indexing difficult for younger ages., Study Design: Healthy children (n = 400; 52% boys, 0-18 years of age) from 2 different European hospitals were studied to derive a simplified formula. Left ventricular mass (LVM) was calculated according to the Devereux formula. The derived approach to index LVM was tested on a validation cohort of 130 healthy children from a different hospital center., Results: There was a strong nonlinear correlation between height and LVM. LVM was best related to height to a power of 2.16 with a correction factor of 0.09. Analysis of residuals for LVM/[(height(2.16)) + 0.09] showed an homoscedastic distribution in both sexes throughout the entire height range. A partition value of 45 g/m(2.16) was defined as the upper normal limit for LVM index. As opposed to formula suggested by current guidelines (ie, LVM/height(2.7)) when applying the proposed approach in the validation cohort of 130 healthy participants, no false positives for LVH were found (0% vs 8%; P < .01)., Conclusions: Our data support the possibility to have a single partition (ie, 45 g/m(2.16)) value across the whole pediatric age range to identify LVH, without the time-consuming need of computing specific percentiles for height and sex., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objectives: Newer parameters of cardiac mechanics provide additional insights on cardiac dysfunction in adult patients with CKD. The aim of this study was to identify prevalence of subclinical abnormalities in cardiac function through the analysis of novel indices of cardiac mechanics in a large population of children with CKD., Design, Setting, Participants, & Measurements: Between 2009 and 2011, the prospective observational Cardiovascular Comorbidity in Children with CKD Study enrolled patients with CKD ages 6-17 years old with eGFR=10-45 ml/min per 1.73 m(2) in 14 European countries. Cardiac morphology and function were assessed through echocardiography. The analysis presented encompasses global radial, longitudinal, and circumferential strains as well as time to peak analysis. Data were compared with 61 healthy children with comparable age and sex., Results: Data on 272 patients with CKD with complete echocardiographic assessment are reported (age =12.8±3.5 years old; 65% boys). Patients with CKD showed mildly higher office BP values and higher prevalence of left ventricular hypertrophy, but no differences were observed among groups in left ventricular ejection fraction. Strain analysis showed significantly lower global radial strain (29.6%±13.3% versus 35.5%±8.9%) and circumferential strain components (-21.8%±4.8% versus -28.2%±5.0%; both P<0.05) in patients with CKD without significant differences observed in longitudinal strain (-15.9%±3.4% versus -16.2%±3.7%). Lower values of global radial strain were associated with lower circumferential endocardial-to-epicardial gradient (r=0.51; P<0.01). This association remained significant after adjusting for BP, eGFR, and presence of left ventricular hypertrophy. Eventually, patients with CKD also showed higher delay in time to peak cardiac contraction (58±28 versus 37±18 milliseconds; P<0.05)., Conclusions: A significant proportion of children with CKD show impaired systolic mechanics. Impaired systolic function is characterized by lower radial strain, transmural circumferential gradient, and mild cardiac dyssynchrony. This study suggests that analysis of cardiac strain is feasible in a large multicenter study in children with CKD and provides additional information on cardiac pathophysiology of this high-risk population., (Copyright © 2015 by the American Society of Nephrology.)

Unlabelled: The aim of this study was to analyse the relationship between insulin-glucose metabolism, nocturnal blood pressure dipping and nonalcoholic fatty liver disease (NAFLD) in obese adolescents without diabetes. One hundred one consecutive children, with biopsy-proven NAFLD, were included in this study. Blood samples were drawn for the analyses of liver function tests, insulin-glucose metabolism and lipid profile appraisal. An ambulatory blood pressure measurement (ABPM) was performed. Seventy-six children (75.3 %) were systolic nondippers, and 23 of them were diastolic nondippers (30.3 %). No differences were found in the anthropometric parameters between the two groups. When compared to the systolic dippers, the systolic nondippers had higher medians of mean nocturnal blood pressure, glucose at 0, 60 and 120 min in the oral glucose tolerance test (OGTT), OGTT insulin at all time points and insulin-resistance values. No correlation of histopathological features with dipping/nondipping statuses was found., Conclusions: We found an association between a nocturnal blood pressure fall and measures of insulin levels, independent of obesity, or daytime blood pressure levels, among the obese patients with NAFLD. Although no association between nondipping profiles and NAFLD was observed in our study, further studies with a longer term follow-up are needed, to better elucidate the complex link between these particular entities.

The burden of hypertension has become increasingly prevalent in children. Hypertension that begins in childhood can carry on into adulthood, therefore early detection, accurate diagnosis and effective therapy of high blood pressure may improve long-term outcomes of children and adolescents. As far as pediatric hypertension is concerned, doubts still persist about the right instruments, modalities and standards of reference that should be used in routine practice. Due to the dynamic process of growth and development, many physiological parameters undergo intensive change with age. Therefore, in children, the definition of hypertension can not rely on a single blood pressure level but should be based on age- and height-specific percentiles. In this review, we introduce the nephrologist to the correct definition of high blood pressure in children. Moreover, we specifically address the main characteristics of different modalities for blood pressure measurement in children, focusing on practical aspects. The latest international guidelines and appropriate standards of reference for office, ambulatory and home blood pressure data collection are presented. As clinicians are being faced with a greater number of children with hypertension, they should be aware of these peculiarities.

The European Society of Hypertension has recently published its recommendations on prevention, diagnosis and treatment of high blood pressure in children and adolescents. Taking this contribution as a starting point the Study Group of Hypertension of the Italian Society of Pediatrics together with the Italian Society of Hypertension has conducted a reappraisal of the most recent literature on this subject. The present review does not claim to be an exhaustive description of hypertension in the pediatric population but intends to provide Pediatricians with practical and updated indications in order to guide them in this often unappreciated problem. This document pays particular attention to the primary hypertension which represents a growing problem in children and adolescents. Subjects at elevated risk of hypertension are those overweight, with low birth weight and presenting a family history of hypertension. However, also children who do not present these risk factors may have elevated blood pressure levels. In pediatric age diagnosis of hypertension or high normal blood pressure is made with repeated office blood pressure measurements that show values exceeding the reference values. Blood pressure should be monitored at least once a year with adequate methods and instrumentation and the observed values have to be interpreted according to the most updated nomograms that are adjusted for children's gender, age and height. Currently other available methods such as ambulatory blood pressure monitoring and home blood pressure measurement are not yet adequately validated for use as diagnostic instruments. To diagnose primary hypertension it is necessary to exclude secondary forms. The probability of facing a secondary form of hypertension is inversely proportional to the child's age and directly proportional to blood pressure levels. Medical history, clinical data and blood tests may guide the differential diagnosis of primary versus secondary forms. The prevention of high blood pressure is based on correct lifestyle and nutrition, starting from childhood age. The treatment of primary hypertension in children is almost exclusively dietary/behavioral and includes: a) reduction of overweight whenever present b) reduction of dietary sodium intake c) increase in physical activity. Pharmacological therapy will be needed rarely and only in specific cases.

Background and Objectives: Left ventricular hypertrophy (LVH) and abnormal systolic function are present in a high proportion of children with CKD. This study evaluated changes in left ventricular (LV) geometry and systolic function in children with mild to moderate CKD as an ancillary project of the Effect of Strict Blood Pressure Control and ACE Inhibition on Progression of Chronic Renal Failure in Pediatric Patients trial., Design, Setting, Participants, & Measurements: Echocardiograms and ambulatory BP monitoring were performed at baseline and at 1- or 2-year follow-up in 84 patients with CKD and 24-hour mean BP above the 50th percentile and/or receiving fixed high-dose angiotensin converting enzyme inhibition and randomized to conventional or intensified BP control., Results: LVH prevalence decreased from 38% to 25% (P<0.05). Changes in LV mass index (LVMI) were restricted to patients with LVH at baseline (-7.9 g/m(2.7); P<0.02). Changes in LVMI were independent of randomization, reduction in BP, hemoglobin, and estimated GFR. A significant increase in midwall fractional shortening was observed in the total cohort (P<0.05), and was greater in the intensified group compared with the conventional BP control group (12%±1.9% versus 8%±1.5%; P=0.05). In multivariate analysis, improvement in myocardial function was associated with reduction in BP (r=-0.4; P<0.05), independently of LVMI reduction., Conclusions: In children with CKD, angiotensin converting enzyme inhibition with improved BP control, LVH regression, and improved systolic function was observed within 12 months. Lowering BP to the low-normal range led to a slightly more marked improvement in myocardial function but not in LVMI.

Background and Objectives: Clinical and experimental data have shown that differences in nephron endowment result in differences in renal mass and predisposition to chronic renal failure, hypertension, and proteinuria. We hypothesized that a significant proportion of the variance in GFR, as estimated by serum creatinine, is attributable to differences in renal size in normal children., Design, Setting, Participants, & Measurements: A total of 1748 normal renal ultrasounds that were performed in children older than 6 months were reviewed. For each ultrasound, serum creatinine, serum blood urea nitrogen, and systolic and diastolic office BP were recorded. Renal size was evaluated as a function of renal length and thickness. All data were normalized for height, weight, age, and gender., Results: When expressed as SD scores, a significant correlation was found between kidney size and serum creatinine (P < 0.0001) and between kidney size and serum blood urea nitrogen (P < 0.002). When dividing kidney size data per quintiles, a difference of 0.51 SD score in serum creatinine was observed between the lowest and highest quintile. No significant correlation was found with office BP measurements., Conclusions: These data show that, even in the normal pediatric population, differences in renal function are significantly explained by differences in renal mass. Methodologic limitations of this study are likely to underestimate this relationship.

Left ventricular (LV) hypertrophy (H) and hypertension are prevalent in children with end-stage renal disease (ESRD) and after renal transplantation. Severe hypertension prior to renal transplantation has traditionally been an indication for native kidney nephrectomy. The impact of nephrectomy on cardiovascular disease has not been well documented. We retrospectively evaluated echocardiographic and ambulatory blood pressure monitoring (ABPM) data in 67 young adults who had undergone transplantation in the pediatric age with a mean follow-up of 10.4 years. Unilateral or bilateral nephrectomies had been performed in 32 patients. The number of antihypertensive drugs used prior to transplantation was significantly higher in the nephrectomized groups. At follow-up the amount of antihypertensive medications was similar between groups and no significant differences were observed in mean arterial blood pressure (MAP) or LV mass index (LVMi). LVH was observed in 50% of non-nephrectomized patients, 45.4% of patients with unilateral nephrectomy, and 44.4% of patients without native kidneys (p = n.s.). In conclusion, unilateral or bilateral nephrectomies prior to transplantation do not appear to influence blood pressure control or the prevalence of LVH after renal transplantation. Longitudinal studies with repeated assessment of LVMi, before and after renal transplantation, are needed to assess the impact of residual activity of native kidneys on arterial blood pressure and cardiac structural changes, even in normotensive patients, to evaluate cardiovascular morbidity.

Increased left ventricular (LV) mass in children with chronic renal insufficiency (CRI) might be adaptive to sustain myocardial performance in the presence of increased loading conditions. It was hypothesized that in children with CRI, LV systolic function is impaired despite increased LV mass (LVM). Standard echocardiograms were obtained in 130 predialysis children who were aged 3 to 18 yr (59% boys) and had stages II through IV chronic kidney disease and in 130 healthy children of similar age, gender distribution, and body build. Systolic function was assessed by measurement of fractional shortening at the endocardial (eS) and midwall (mS) levels and computation of end-systolic stress (myocardial afterload). The patients with CRI exhibited a 6% lower eS (33.1 +/- 5.5 versus 35.3 +/- 6.1%; P < 0.05) and 10% lower mS (17.8 +/- 3.1 versus 19.7 +/- 2.7%; P < 0.001) than control subjects in the presence of significantly elevated BP, increased LVM, and more concentric LV geometry. Whereas the decreased eS was explained entirely by augmented end-systolic stress, mS remained reduced after correction for myocardial afterload. The prevalence of subclinical systolic dysfunction as defined by impaired mS was more than five-fold higher in patients with CRI compared with control subjects (24.6 versus 4.5%; P < 0.001). Systolic dysfunction was most common (48%) in patients with concentric hypertrophy and associated with lower hemoglobin levels. CRI in children is associated with impaired intrinsic LV contractility, which parallels increased LVM.

Left ventricular hypertrophy (LVH) is the most important independent marker of cardiovascular risk in adults with chronic kidney disease. Cardiovascular morbidity seems increased even in children with chronic renal insufficiency (CRI), but the age and stage of CRI when cardiac alterations become manifest are unknown. For assessing the prevalence and factors associated with abnormal LV geometry in children with CRI, echocardiograms, ambulatory BP monitoring, and biochemical profiles were obtained in 156 children aged 3 to 18 yr with stages 2 through 4 chronic kidney disease (GFR 49 +/- 19 ml/min per 1.73 m2) and compared with echocardiograms obtained in 133 healthy children of comparable age and gender. LV mass was indexed to height2.7. Concentric LV remodeling was observed in 10.2%, concentric LVH in 12.1%, and eccentric LVH in 21% of patients. LVH was more common in boys (43.3 versus 19.4%; P < 0.005). Probability of LVH independently increased with male gender (odds ratio [OR] 2.62; P < 0.05) and standardized body mass index (OR 1.56; P = 0.01). Low hemoglobin, low GFR, young age, and high body mass index were independent correlates of LV mass index (0.005 < P < 0.05). LV concentricity (relative wall thickness) was positively associated with serum albumin (P < 0.05). Probability of abnormal LV geometry increased with C-reactive protein >10 mg/dl (OR 26; P < 0.001). In conclusion, substantial cardiac remodeling of both concentric and eccentric type is present at young age and early stages of CRI in children. Prevalence of LVH is related to male gender, anemia, and ponderosity but not to BP. Additional effects of volume status and inflammation on cardiac geometry are also evident.

Background: Abnormal cardiovascular reactivity at rest and during physical exercise may be a risk factor for left ventricular hypertrophy (LVH) in pediatric renal transplanted (Tx) patients. Data on total peripheral vascular resistance (TPR) are not available., Methods: Eleven renal Tx patients treated with cyclosporine (7 females and 4 males; mean age 14.6 +/- 3.3 years; mean time since transplantation 43 +/- 35 months) were evaluated for 24-hour blood pressure (BP), TPR and echocardiographic left ventricular mass (LVM). TPR values of patients were compared with data of a group of 11 healthy controls matched for sex and age., Results: Twenty-four-hour ambulatory blood pressure monitoring showed that all but one patient had normal daytime BP values and six patients showed a reduced or inverse nocturnal dip. LVH was found in 72% of the patients. In comparison with healthy controls, patients showed significantly elevated TPR at rest and during exercise suggesting an increased vascular tone. The degree of LVH in these patients is severe and appears disproportionate to the BP values., Conclusion: The high incidence of LVH can reflect an augmented cardiovascular reactivity associated with a disturbed circadian pattern. The increase in TPR and the reduction of the nocturnal fall of BP also might contribute to the development of LVH in young renal Tx patients.

Background: Ambulatory blood pressure monitoring (ABPM) has been found to be of significant importance in clinical practice because numerous blood pressure (BP) measurements may be made throughout the 24-hour period., Objective: To assess the clinical utility of ABPM in children with secondary hypertension., Methods: We studied 37 patients (21 boys and 16 girls), with a mean age of 16.4 +/- 4.1 years, after kidney transplantation and 38 patients (27 boys and 11 girls), with a mean age of 10.2 +/- 2.1 years, after surgical correction of aortic coarctation. Data, expressed as mean +/- SD, were analyzed after dividing the patients into 4 groups. Group A consisted of 25 patients receiving antihypertensive therapy; group B included 12 patients not receiving antihypertensive therapy. Group C included 25 patients operated on before 3 years of age (8 +/- 7 months of age); group D included 13 patients operated on after 3 years of age (74 +/- 29 months of age)., Results: In groups A and B, casual BP measurement showed that 16 of 37 patients (43%) were hypertensive; 24-hour ABPM detected a larger number of patients who were hypertensive (23 of 37, 62%); there were 18 in group A and 5 in group B. In groups C and D, casual BP measurement identified 6 of 38 (15%) patients as hypertensive, whereas 24-hour ABPM again identified a higher number (13 of 38, 34%)., Conclusions: Our findings confirm that 24-hour ABPM is more sensitive than casual BP in detecting abnormal BP in patients at high risk for secondary hypertension.

Background: Hypertension and left ventricular hypertrophy (LVH) are possible complications in pediatric patients after renal transplantation., Methods: We performed left ventricular echocardiography, 24-hour ambulatory blood pressure monitoring (24-hr ABPM), and treadmill tests in 28 pediatric renal transplant patients (mean age 16.1 +/- 3.7; time since transplantation 36 +/- 23 months). Left ventricular mass (LVM) was indexed for height 2.7., Results: LVH was found in 82% of the patients. Seven of these patients were normotensive by 24-hour ABPM, but five patients showed a hypertensive systolic BP response during the treadmill test. LVM/height 2.7 correlated significantly with the mean 24-hour systolic BP (P = 0.002) and with the maximal exercise systolic BP (P = 0.002)., Conclusion: LVH is frequent in pediatric renal transplant patients. More information is needed with respect to the risk for LVH, including data from 24-hour ABPM and treadmill testing.

The aim of the study was to assess exercise tolerance and blood pressure (BP) response to treadmill exercise in children after renal transplantation. Forty-five children were selected (29 males and 16 females) whose mean age was 14.3 +/- 4.2 years. All children had Hb >/= 10 g/dl and creatinine clearance >/=40 ml/min/1.73 m2. They were at least 6 months posttransplantation and were on triple immunosuppressive therapy. Twenty-seven were also on various antihypertensive medications. Each underwent clinical examination and measurement of BP, both at rest and during exercise testing on treadmill. The test was stopped on muscular fatigue or exhaustion. The patients were divided into two groups: those off (A) or on (B) antihypertensive therapy. When compared to a population of healthy children the patients had reduced exercise tolerance (10.1 +/- 2.1 vs 15.1 +/- 1.7 min, p < 0.001) (67 +/- 16%), increased heart rate (174 +/- 19 vs 161 +/- 19 beats/min, p < 0.001) (109 +/- 15%), and increased maximum systolic BP (150 +/- 26 vs 134 +/- 13 mmHg, p < 0. 001) (113 +/- 19%) at comparable workloads. Within the two patient groups, significant differences were observed during exercise testing for maximum heart rate, which was lower in group B (p = 0.03), and maximum systolic BP, which was higher in group A (p = 0.04). Our study confirms that children and adolescents on immunosuppressive therapy after renal transplantation have a hypertensive response during exercise, probably related to medication-induced peripheral vascular tone.

The results of ambulatory blood pressure monitoring (ABPM) in children after kidney transplant were analyzed to ascertain any alteration in circadian BP profile, degree of hypertension, and efficacy of therapy. The data were also compared with casual BP data and left ventricular mass index (LVMI). We have examined 30 patients (17 male, 13 female), mean age 16.1+/-3.6 years after kidney transplant. All patients were receiving triple immune-suppressive therapy and 20 of them were also taking antihypertensive therapy. They underwent clinical examination with measurement of BP at rest, echocardiogram mono-2D, and ABPM. The following ABPM parameters were recorded: systolic (S) and diastolic (D) BP at rest; mean 24-h SBP and DBP; mean daytime SBP and DBP; mean nighttime SBP and DBP; nocturnal fall in SBP and DBP; and mean daytime and nighttime heart rate (HR). The patients were divided in two groups. Group A consisted of 20 patients taking antihypertensive treatment; group B consisted of 10 patients not taking antihypertensive treatment. Casual and ABPM data for the two groups were compared using the Student t test for unpaired data. Blood pressure at rest and LVMI were not statistically different between the two patient groups. The ABPM data showed statistical differences between the two groups for mean 24-h SBP and DBP, daytime and nighttime SBP, nighttime DBP, fall in nocturnal DBP, and nighttime HR. Mean 24-h SBP and DBP, mean daytime SBP and DBP, and mean nighttime SBP and DBP were significantly correlated to LVMI (respectively, P = .009, P = .005, P = .008, P = .007, P = .05, and P = .01). Twenty-four-hour ABPM was more useful in the diagnosis and management of hypertension than was casual BP at rest.

A 12-year-old girl affected by idiopathic dilated cardiomyopathy and renal failure was referred to our institution for cardiac transplantation. A simultaneous heart-kidney transplantation from the same donor was decided. The immunosuppression schedule consisted of azathioprine, antithymocyte globulin, steroids, and cyclosporine. At a follow-up visit at 24 months after transplantation, no episodes of heart or kidney rejection had occurred and cardiac and renal function were good. Concomitant failure of heart and kidney is well known in the literature, but it appears to be more frequent in adult as compared with the pediatric population. This is the first case of combined heart and kidney transplantation in a child. Because of the successful outcome and good follow-up, the number of combined organ transplantations will most likely increase in the future.

We investigated the cardiovascular and respiratory conditions, at rest and in response to stress testing, in 10 children and adolescents with successful renal transplantation, to release certifications for participation in sports. Our patients were aged more than 6 years, transplanted 6 months or more before the study, with creatinine clearance > 40 ml/min/1.73 m2, without hypertension at rest. All but 1 were on cyclosporine A, prednisone and azathioprine. Two control study groups with the same chronological age and body surface area were paired with our patients. They underwent a graded exercise tread-mill test, during which maximal blood pressure and heart rate were recorded. Resting electrocardiogram, dynamic 24-hour electrocardiogram Holter monitoring and mono- and bidimensional echocardiograms were obtained before the test. Spirometry was performed to study lung flow and volume. A questionnaire collected information about physical activity patterns. Four categories, according to practice, frequency and duration of exercise, were identified: nonactive, starters, experienced and very experienced. Most children and adolescents were sedentary or mildly interested in sports and during treadmill test we observed reduced exercise capacity and systolic hypertensive response to increasing exercise testing.

Seventy-six cases of haemolytic-uraemic syndrome (HUS) were collected over a 4-year period during a surveillance and case-control study. The annual incidence of 0.2 per 100,000 children aged 0-14 years is lower than in other countries; 34% had no prodromal diarrhoea. Evidence for verocytotoxin-producing Escherichia coli (VTEC) infection was found in 72% of patients and 3% of controls; 88% of patients with bloody diarrhoea, 67% with non-bloody diarrhoea and 55% without diarrhoea were VTEC positive. Seventy-three percent of patients had creatinine clearance > or = 80 ml/min per 1.73 m2, normal blood pressure, no proteinuria and haematuria < 2+ after 1 year of follow-up. One patient died and none had non-renal sequelae. VTEC positivity was significantly correlated with a good outcome, while the absence of diarrhoea and a high total white blood cell count at onset were not predictors of a bad outcome. Household contacts of HUS patients had diarrhoea more frequently than those of the control group, supporting the hypothesis of person-to-person transmission of VTEC infection.

In a 3-year prospective study, 49 Italian children with the hemolytic-uremic syndrome (HUS) were examined for evidence of infection with Vero cytotoxin-producing Escherichia coli (VTEC). Diagnosis of infection was established in 37 patients (75.5%) by the combined use of stool examination for VTEC and for free fecal neutralizable Vero cytotoxin and serum analysis for antibodies to the Vero toxins and the lipopolysaccharides (LPS) of three major VTEC serogroups (O157, O26, O111). Anti-LPS antibodies were detected in sera from 30 patients: 25 had antibody to O157 LPS, 4 to O26, and 1 to O111. In as many as 27 patients (55.1%), diagnosis of infection relied only on serologic findings, and the presence of antibody to LPS was the sole evidence of VTEC infection in 20 patients (40.8%). The use of LPS from different E. coli serogroups provided evidence that in Italy O157 strains are the most prevalent VTEC involved in HUS.

Verotoxin-producing Escherichia coli O157:H7 was isolated for the first time in Italy from a child with hemolytic-uremic syndrome and his asymptomatic sister. Both parents remained asymptomatic, and neither had evidence of this infection. The source of the infection was not identified, but the children had eaten ground beef during the 15 days prior to the onset of symptoms.

The effects of 25-OHD3 on renal osteodystrophy have been studied in 6 patients on maintenance haemodialysis. Administration of 25-OHD3, 50 microgram/day, did not improve biochemical data and intestinal absorption of calcium. With a dose of 100 microgram/day in all patients an increase in blood calcium levels eventually reaching hypercalcemic values was observed. In two cases a fall in alkaline phosphatase toward normal values was noted. In the same cases the treatment-induced hyperphosphatemia, uncontrolled by AI(OH)3 supplementation and similarly high iPTH levels were observed. In two cases repeated bone biopsy following 8 months treatment and not show substantial improvement of bone lesions. In one case addition of 1,25-(OH)2D3 to the treatment with 25-OHD3 led to a more rapid improvement in biochemical parameters and iPTH serum levels. Doses of 25-OHD3 capable to correct blood calcium levels and intestinal absorption of calcium, may have minimal benefit on the osteitis fibrosa component of the bone lesion.

Serum levels of 25 hydroxycholecalciferol were evaluated following i.m. and p.o. vit. D2 and D3 and p.o. 25OHD3 administration. While no increment in 25OHD3 serum levels were observed after i. m. administration of non-hydroxylated calciferols, a marked increment of the metabolite was found following the oral administration. However the peak values were largely impredictable. Acute and chronic p.o. administration of 25OHD3 determines a rapid and dose-dependent increase of the serum levels of the metabolite. In addition considering that a lower dosage is required of 25OHD3 compared to vit. D, this metabolite is preferable in the therapeutic use.

The aim of our work was to evaluate the immediate effects of acetate-dialysis in patients with normal renal and respiratory function. For this purpose pH, pO2, pCO2 and HCO3- were monitored in arterial blood before dialysis, after 60, 120, 180 mns and at the end of each treatment in two groups of patients on chronic hemodialysis, a first group of schizophrenic patients and a second group of uremic patients. In the first group of patients the predialytic values were in the normal range. After hemodialysis HCO3- and pCO2 significantly decreased, both these changes were associated with a stable pH. The pO2 significantly decreased after 60 mns of dialysis. At the end of dialysis the pO2 increased without significant variation compared to predialytic values. In conclusion in non-uremic hemodialysis patients metabolic acidosis due to the loss of bicarbonate through the membrane is compensated by respiratory alkalosis. This respiratory alkalosis is not due to hypoventilation secondary to respiratory centre inhibition, but is mainly due to the pCO2 loss through the dialysis membranes.