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Purpose Head-to-head comparison of Diffusion Weighted Imaging (DWI) and Acoustic Radiation Force Impulse (ARFI) elastography regarding the characterization of breast lesions in an assessment setting. Method Patients undergoing an ultrasound examination including ARFI and an MRI protocol including DWI for the characterization of a BI-RADS 3–5 breast lesion between 06/2013 and 10/2016 were eligible for inclusion in this retrospective, IRB-approved study. 60 patients (30–84 years, median 50) with a median lesion size of 16 mm (range 5–55 mm) were included. The maximum shear wave velocity (SWVmax) and mean apparent diffusion coefficient (ADCmean) for each lesion were retrospectively evaluated by a radiologist experienced in the technique. Histology was the reference standard. Diagnostic performances of ARFI and DWI were assessed using ROC curve analysis. Spearman’s rank correlation coefficient and multivariate logistic regression were used to investigate the independence of both tests regarding their diagnostic information to distinguish benign from malignant lesions. Results Corresponding areas under the ROC curve for differentiation of benign (n = 16) and malignant (n = 49) lesions were 0.822 (ARFI) and 0.871 (DWI, p-value = 0.48). SWVmax and ADCmean values showed a significant negative correlation (ρ = −0.501, p-value Conclusion Significant correlation between quantitative findings of ARFI and DWI in breast lesions exists. Thus, ARFI provides similar diagnostic information as a DWI-including protocol of an additional “problem-solving” MRI for the characterization of a sonographically evident breast lesion, improving the immediate patient management in the assessment setting.

BackgroundIn women at high/intermediate lifetime risk of breast cancer (BC-LTR), contrast-enhanced magnetic resonance imaging (MRI) added to mammography ±ultrasound (Mx±US) increases sensitivity but decreases specificity. An alternative strategy, MRI alone, potentially more cost-effective, has never been explored. This study aims to assess the characteristics of women who participated in a randomized trial offering MRI alone.MethodsIn this feasibility multicentre randomized controlled trial we compared MRI alone versus Mx+US in women at intermediate BC-risk (allocation ratio 1:1). Eligible women were aged 40 –59, with a 15–30% LTR and/or extremely dense breasts. Two screening rounds per woman were planned in ten centres experienced in MRI screening. Primary endpoint: rate of cancers detected in the two arms after 5 years of follow-up. Secondary endpoints: distribution of the risk profiles among the women enrolled in the trial; distribution of pathological stages and histology of cancers detected; interval cancer rate in the two arms.ResultsFrom 07/2013 to 11/2015, 1,254 women (mean age 47 years) were enrolled: 624 were assigned to Mx+US, 630 to MRI. Most of them were aged below 50 (72%) and premenopausal (45%), 52% used oral contraceptives. Among postmenopausal women, 15% had used hormone replacement therapy. Breast and/or ovarian cancer in mother and/or sisters were reported by 37% of enrolled women, extreme breast density was recorded for 79%, 41% had a 15–30% BC-LTR.ConclusionsThe distribution of BC-risk profile major determinants (breast density and family of breast and ovarian cancer) of enrolled women varied across centres.Trial registrationNCT02210546Key pointsMammography plus ultrasound are commonly used to screen women with dense breastsSupplemental ultrasound increases BC detection rate but also false-positives and potential overdiagnosisWhether increased BC detection by US translates into reduced mortality is unknownMRI alone could be more risk- and cost-effective than mammography plus ultrasound

Introduction Breast metastases are very uncommon, either from solid tumors or malignant melanoma. Case report We present the case of a 42-year-old woman with a history of cutaneous melanoma of the shoulder excised 21 years ago. She presented with a palpable lump in the upper outer quadrant of the right breast. Ultrasound demonstrated a solid mass within a cystic lesion. A core biopsy was taken and first histology reported a poorly differentiated primary breast cancer suspected to be triple negative. MRI detected a satellite lesion in the same breast, a focus of suspected enhancement in the other breast, and the extramammary finding of an enhancing pulmonary lesion. Staging computed tomography detected widespread metastases to the lungs, brain, subcutaneous left shoulder, liver, pancreas, and hepatorenal recess. A core biopsy was taken from the left breast lesion and the previous slides were reviewed; histopathology and immunohistochemistry were in keeping with metastasis from melanoma. Conclusions The possibility of a metastatic lesion to the breast should be taken into account in any patient presenting with a breast lump and a previous history of melanoma. Breast involvement cannot be considered an isolated finding, as it might be the first manifestation of widespread disease.

Aim To estimate the prevalence of cerebral aneurysms in patients previously treated for left cardiac myxoma (LCM). Materials and methods This prospective institutional review board-approved study included patients treated for LCM. All patients treated at our institution (IRCCS Policlinico San Donato, Italy) were telephoned and those enrolled underwent unenhanced brain magnetic resonance imaging (MRI) using sagittal T1-weighted turbo spin-echo (TSE); axial T2-weighted TSE; axial fluid-attenuated inversion-recovery; axial echo-planar diffusion-weighted; and three-dimensional time-of-flight angiographic sequences. Results Seventy-six patients were telephoned, and data regarding their clinical history since tumor resection were obtained for 49 patients (64%). Four of the 49 (8%) patients were deceased, one due to a cerebral hemorrhage from a ruptured cerebral aneurysm 8 years after tumor resection. One patient had a pacemaker preventing MRI. Of the remaining 44 patients, 31 refused MRI and 13 were enrolled (10 females; mean age 64 years). Three of the 13 (23%; two females; 59–78 years) were diagnosed with a cerebral aneurysm, from 2 mm to 4–5 mm in diameter, involving the right middle cerebral artery (n = 2) or the right internal carotid artery (n = 1). Including the deceased patient, the resulting prevalence was 4/14 (29%). Conclusion From this preliminary study, one-third of patients treated for LCM may present with a cerebral aneurysm. Longitudinal large studies are needed to further clarify this matter.

Background: Oxidative stress has been related to hypo-response to erythropoiesis-stimulating agents (ESAs) in hemodialysis (HD) patients. The aim of this study was to verify whether vitamin E (ViE) on a synthetic polysulfone dialyzer can improve ESA responsiveness. Methods: This controlled, multicenter study involved 93 HD patients on stable ESA therapy, who were randomized to either ViE-coated polysulfone dialyzer or to a low-flux synthetic dialyzer. The primary outcome measure was the change in ESA resistance index (ERI) from baseline. Results: Mean ERI decreased in the ViE group by 1.45 IU/kg*g/dl and increased in the control group by 0.53 IU/kg*g/dl, with a mean difference of 1.98 IU/kg*g/dl (p = 0.001 after adjusting for baseline ERI, as foreseen by the study protocol). Baseline ERI was inversely related to its changes during follow-up only in the control group (R2 = 0.29). Conclusions: The ViE dialyzer can improve ESA response in HD patients. Changes in ERI during follow-up are independent from baseline ERI only in the ViE group. Video Journal Club ‘Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=453442.

Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.

Purpose: Anemia in chronic kidney disease dialysis patients is a complex syndrome involving many causes. Adequate dialysis can contribute to its correction through many mechanisms, including the removal of molecules that may inhibit erythropoiesis. The aim of this pilot study was to evaluate the effect on renal anemia of two synthetic, high-flux dialyzers (polynephron vs. high-flux polysulphone). Methods: 20 dialysis patients (11 male; mean age: 72 years) were randomly assigned and studied for 6 months. There were 2 dropouts in each group. Each patient underwent 3 hemodialysis treatments per week without any difference in dialysis prescription. At T = 0 and T = 6 (after 6 months), instantaneous plasma clearances and reduction rates of small solutes, β2-microglobulin protein (β2-μ); hemoglobin (Hb), and iron pattern were measured. The effect on anemia was evaluated by calculating the Erythropoesis Stimulating Agent (ESA) doses and the Erythropoietin Resistance Index (ERI). Results: Kt/V increased between T0 and T6 in both groups. β2-μ pre-dialysis levels significantly decreased between T0 and T6 in both dialyzer groups (pConclusions: High-flux filters improved Hb levels, although only significantly in the polynephron group, suggesting a possible different effect. The results should be interpreted with caution and tested in an appropriately powered, large, prospective, randomized control trial.

OBJECTIVE This study aimed to estimate the frequency and timing of washout in a series of pathologically proven benign mass-like breast lesions at dynamic magnetic resonance imaging. METHODS Institutional review board approval was obtained for this retrospective study. We evaluated enhancement kinetics of 33 pathologically confirmed benign breast lesions: fibroadenomas (n = 22), adenosis (n = 6), typical ductal hyperplasia (n = 2), fibroadenoma with ductal hyperplasia (n = 1), fibrosclerosis (n = 1), and inflammatory lesion (n = 1). Coronal 3-dimensional T1-weighted gradient-echo sequences were acquired before/after intravenous injection of 0.1 mmol/ kg gadoterate meglumine (time resolution, 111 seconds), 1 before and 5 after contrast injection. The time point at which the kinetic curve demonstrated a washout was recorded. Cumulative distribution of lesions showing washout was built. Paired comparisons of specificity for washout kinetics were performed using the McNemar test. RESULTS Of 33 lesions, washout was never observed in 20 (61%), whereas 13 (39%) showed washout during the study. Of these 13 lesions, only 1 (inflammatory mass) exhibited washout within the first 3 minutes (specificity, 97%), 9 within 6 minutes (specificity, 73%), and 13 within 8 minutes (specificity, 61%). Specificity of washout kinetics within 3 minutes (97%) was significantly larger than that from the sixth minute (73%) and thereafter (P < 0.016). CONCLUSIONS A prolonged observation for dynamic breast magnetic resonance imaging may result in false-positive washout, especially after 6 minutes. Late washout should not be considered a reliable marker of malignancy.

Background: In renal transplant recipients (RTR) an increased risk to develop cardiovascular injury is present. Transthoracic Doppler echocardiographic assessment of coronary flow velocity reserve (CFVR), a sensitive and minimally invasive technique, was recently employed to detect both macrovascular and microvascular coronary artery disease (CAD) in different clinical settings. The prevalence of coronary involvement in young adult RTR is still unknown. The aim of the study was to investigate the presence of early cardiovascular damage in asymptomatic young adult RTR. Methods: Transthoracic Doppler echocardiographic-derived CFVR and common carotid intima-media thickness (IMT) were assessed in 25 asymptomatic young adult RTR (mean age 25.7 ± 7.0 years; range 17.3–43.9) without CAD and 25 healthy controls. Results: CFVR was lower in young adult RTR compared to controls (2.8 ± 0.6 vs. 3.5 ± 0.8; P < 0.001), meanwhile left ventricular wall motion and common carotid IMT were comparable in both groups. We found a negative correlation between CFVR and age (r = −0.50; P = 0.018) and months on dialysis (r = −0.54; P < 0.01). Conclusions: Young adult RTR showed a reduced CFVR reflecting an impaired coronary microcirculation, which is significantly related to the age and duration of dialysis; coronary microvascular damage is detectable in the absence of changes in common carotid IMT. Non-invasive evaluation of CFVR by transthoracic stress echocardiography could be a reliable method for identification of early coronary microvascular involvement in young adult RTR.

Little is known about the role of proteinuria in the progression of childhood renal diseases. We analyzed the decline in creatinine clearance (CCr) and kidney survival in 225 children (185 males) with chronic renal failure (CRF) due to isolated hypodysplasia or hypodysplasia associated with urological abnormalities. The data were based on the information available in the Italian Pediatric Registry of CRF (ItalKid Project), which includes patients from all of Italy aged 0.9) n=71. Patients in groups A and B showed a significantly slower decline in CCr than those in group C (slope +0.16±3.64 and −0.54±3.67 vs. −3.61±5.47, P

Today, hemodialysis (HD) represents a rescue therapy for an increasing number of patients worldwide. Thanks to continuous improvements, it is now better tolerated; thus, allowing patients relief from

Many observational studies have consistently shown that high-flux hemodialysis (hf-HD) has positive effects on the survival and morbidity of chronic kidney disease stage 5 dialysis (CKD5D) patients when compared with low-flux hemodialysis, but the primary analysis of the prospective randomized Hemodialysis Outcomes (HEMO) study showed that the use of hf-HD was not associated with a significant reduction of the relative risk of mortality. More recently, the Membrane Permeability Outcome (MPO) study found that survival could be significantly improved by use hf-HD compared with low-flux dialysis in high-risk patients as identified by serum albumin ≤4 g/dl and, in a post-hoc analysis, in diabetic patients. Online hemodiafiltration (HDF) is reported as the most efficient technique of using high-flux membranes. Clearances of small solutes like urea are higher than in hemofiltration and of middle solutes like β(2)-microglobulin are higher than in hf-HD. As the number of randomized prospective trials comparing HDF and hf-HD is still very limited, no conclusive data are available concerning the effect of increased convection of online HDF on survival and morbidity in CKD5D patients. A large, randomized controlled study is needed to clinically confirm the theoretical advantages of online HDF.

Many observational studies have consistently shown that high-flux hemodialysis (hf-HD) has positive effects on the survival and morbidity of chronic kidney disease stage 5 dialysis (CKD5D) patients when compared with low-flux hemodialysis, but the primary analysis of the prospective randomized Hemodialysis Outcomes (HEMO) study showed that the use of hf-HD was not associated with a significant reduction of the relative risk of mortality. More recently, the Membrane Permeability Outcome (MPO) study found that survival could be significantly improved by use hf-HD compared with low-flux dialysis in high-risk patients as identified by serum albumin ≤4 g/dl and, in a post-hoc analysis, in diabetic patients. Online hemodiafiltration (HDF) is reported as the most efficient technique of using high-flux membranes. Clearances of small solutes like urea are higher than in hemofiltration and of middle solutes like β(2)-microglobulin are higher than in hf-HD. As the number of randomized prospective trials comparing HDF and hf-HD is still very limited, no conclusive data are available concerning the effect of increased convection of online HDF on survival and morbidity in CKD5D patients. A large, randomized controlled study is needed to clinically confirm the theoretical advantages of online HDF.

Background. Chronic kidney diseases (CKD) tend to progress to end-stage renal failure (ESRF). As it has been demonstrated that angiotensin-converting enzyme inhibitors (ACEi) have a renoprotective effect in adults with proteinuric disease and may be effective in reducing hyperfiltration and proteinuria, they are also frequently used as anti-progression agents in paediatric patients with CKD despite the lack of data confirming their role in the nephropathies peculiar to children. The aim of this study was to investigate whether patients with hypodysplastic CKD (the most common cause of ESRF in children) treated with ACEi show a significantly slower decline in creatinine clearance (Ccr). Methods. The analysis was based on the information available in the database of the ItalKid Project, a nationwide, population-based registry of chronic renal insufficiency (CRI) in children in Italy. Of the 822 patients with CRI due to hypodysplasia, we selected those who had been continuously treated with ACEi; the control patients were identified from the same diagnostic group and matched for gender, age and baseline Ccr. Results. Progression was analysed as the slope of Ccr in a total of 164 patients: 41 cases and 123 matched controls. There were no significant between-group differences in blood pressure, duration of follow-up or pre-study slope of Ccr (� 0.31 � 2.26 vs � 0.33 � 3.58 ml/min/1.73m 2 /year; P ¼ NS). After an average of 4.9 � 2.3 years, the mean slope of Ccr was 40% lower in the ACEi-treated cases in comparison to controls (� 1.08 � 2.08 vs � 1.80 � 4.42 ml/min/1.73 m 2 / year), however, this difference was not statistically significant (P ¼ 0.31). Conclusions. We conclude that ACEi treatment does not significantly modify the naturally progressive course of hypodysplastic nephropathy in children and further studies are necessary before such treatment is routinely proposed for anti-progression purposes in children with CKD.

Background. Some degree of cardiovascular disease should be suspected in young adults who have been paediatric renal transplant recipients also if no systematic data collection is routinely performed in clinical setting. The aim of our work was to evaluate the degree of cardiovascular damage in these young patients, using a minimally invasive technique. We then evaluated coronary flow reserve (CFR) and carotid intima-media thickness (IMT) in 25 patients (13 males, median age 23.7 years). Methods. Coronary flow velocity on the left anterior descending coronary artery was assessed by transthoracic echocardiography, before and after dipyridamole, after standard echocardiography. CFR was compared with that of a small control group (n ¼ 16; median age 25 yrs). Results. In this relatively young sample, mean CFR was 2.8 � 0.6 (median 2.75), and half of the patients had reduced coronary reserve (P ¼ 0.01). Mean IMT (0.48 � 0.08 mm) was only slightly, though significantly larger compared with the reference standard (P < 0.05) but was significantly thinner in normotensive than in hypertensive patients (0.42 � 0.06 vs 0.49 � 0.05 mm, P < 0.05). The time on dialysis prior to transplantation, hypertension and age at the time of CFR evaluation affect CFR. IMT did not correlate with CFR. Conclusions: CFR and IMT abnormalities are common in young transplant recipients, in spite of the fact that our paediatric population has much less of the atherosclerotic ‘legacy’ common to adult patients.

Almost all the extensions of the Standard Model predict the existence of new charged particles; these particles should be very heavy since they have excaped detection so far. In general, such heavy particles decay as soon as they are produced, but under certain circumstances they can be long-lived or even stable. There are two classes of models which predicts the existence of long-lived particles [3]: models with a weakly broken symmetry, where the particle would be stable if the symmetry were exact; and models with an exact symmetry which forbids the decay of heavy exotics into ordinary particles, where the decay of the charged particle into a neutral particle is suppressed either by small couplings or by phase space. Examples of the second kind are supersymmetric models with exact R-parity, where the lightest supersymmetric particle is the gravitino. In this talk we will focus on GMSB (Gauge Mediated Supersymmetry Breaking) which belongs to this kind of models. In GMSB supersymmetry is broken in a so called hidden sector at a scale \( \sqrt F \) and transmitted to SM particles via a messenger sector. The transmission of the supersymmetry breaking is mediated by gauge fields, in particular by N singlet representations of SU(5).

Little is known about the prescription pattern of antihypertensive drugs for children with impaired kidney function. We have therefore documented the use of antihypertensive drugs in this patient group by evaluating the Italian pediatric population-based registry of patients with chronic kidney disease on conservative treatment (ItalKid) from 1995 to 2003. In 1995, prescriptions written for antihypertensive drugs for use by children were approximately equally divided among drugs blocking the renin-angiotensin system and calcium channel blockers (38 vs. 43% of all prescriptions), followed by beta-blockers and diuretics (15 and 4%, respectively). During subsequent years the proportion of prescriptions for drugs blocking the renin-angiotensin system increased (2003: 61%; p

In the past 10 years, many widely accepted concepts relating to aldosterone production and its pathogenetic role have changed. We now know that aldosterone is produced not only by the zona glomerulosa of the adrenal cortex, but also in the heart, blood vessels, kidney and brain; such extra-epithelial production occurs mainly during tissue repair. Also, increased aldosterone levels contribute to vessel inflammation, oxidative stress, endothelial dysfunction and organ damage. As such, aldosterone has a key role in the development of myocardial fibrosis. Anti-aldosterone treatment has proven effective in patients with heart failure. Experimental evidence regarding the role of aldosterone in kidney damage has accumulated. Aldosterone infusion can counteract the beneficial effects of treatment with angiotensin-converting-enzyme inhibitors, causing more-severe proteinuria and an increased number of vascular and glomerular lesions; treatment with aldosterone antagonists can reverse these alterations. Preliminary observations in pilot studies in humans confirm the experimental findings, supporting the hypothesis that aldosterone antagonists are renoprotective in clinical practice. Studies in larger populations with longer follow-up are needed to confirm this theory.

The clinical management of cyclosporine has evolved greatly during the last decade thanks to the use of pharmacokinetic (PK) studies which confirmed the dose relationship between drug exposure and its biological effects. Therefore, cyclosporine PK monitoring during the early phase of the post-transplant period became essential to avoid over or underexposure to the drug thus preventing the risk of nephrotoxicity or acute rejection episodes. More recently, a simple PK determination based on cyclosporine blood concentration measured 2 h after the morning dose, has proven to be very effective for monitoring cyclosporine exposure in the early postoperative period. In this paper, the authors present a set of PK profiles obtained from a stable, long-term pediatric kidney transplant population and correlate these parameters with the risk of chronic rejection development. The study shows how cyclosporine monitoring based on the sole trough level determination misled a correct therapeutic behavior, as revealed by the PK parameters that were constantly below the therapeutic threshold in a small patient cohort who eventually developed chronic rejection. The C2 determination should be considered as the gold standard for cyclosporine monitoring in long-term pediatric recipients.

Background. The management of cyclosporine therapy in pediatric kidney-transplant recipients is largely based on single center's experience rather than on a univocal pharmacokinetic approach based on therapeutic drug monitoring. A prospective multicenter trial was designed to address the question whether C2 blood level monitoring of cyclosporine microemulsion therapy is feasible in the pediatric setting. Methods. Sixty-four pediatric kidney-transplant recipients receiving a triple immunosuppressive regimen based on cyclosporine microemulsion had their cyclosporine dose adjusted to the same protocol-defined C2 targets from the time of the transplant until 2 years posttransplant. The interim analyses after 1 year of enrolment is presented in this study. Results. One-year patient and graft survival were 100% and 94.8%, respectively. One-year rejection rate was 15%. C2 management of cyclosporine did not affect graft function: 1-year serum creatinine and glomerular filtration rate were 1.3±1 mg/mL and 71.2±20 mL/min/1.73 m 2 , respectively. C2 was the best single-point predictor of the area under the concentration curve throughout the entire follow-up, with a mean coefficient of correlation of 0.97±0.01. Conclusions. C2 management of cyclosporine microemulsion therapy is effective and safe in pediatric kidney-transplant recipients given a combined immunosuppressive treatment.

This open-label, longitudinal, long-term study of de novo pediatric renal transplant recipients was designed to investigate the pharmacokinetics (PK) of mycophenolic acid (MPA) and its possible interaction with cyclosporine (CsA). Thirty-four children on an immunosuppressive regimen of CsA, prednisone, and mycophenolate mofetil (MMF, 300-400 mg/m2 twice daily) were investigated at 6, 30, 180, and 360 days after transplantation. Considerable interindividual variability in the areas under the concentration curve (AUC(0-12)) of MPA was observed during the follow-up, although the dose of MMF remained the same over the same time. Predose levels (C0) increased significantly during the first 6 months after transplantation: C0 at 6 and 180 days after transplantation was 0.8 +/- 0.6 and 1.9 +/- 1.1 microg/mL (P < .0001). A significant time-dependent increase in the AUC of MPA was also observed during the first 6 posttransplant months: AUC(0-12) at 6 and 180 days after transplantation was 23.3 +/- 10.8 and 40 +/- 11.6 mg*h/L (P = .003). MPA concentrations 3 and 4 hours after MMF intake were the individual time points that best correlated with the full MPA AUC (r = 0.8 and 0.79; P < .001). The abbreviated MPA AUC (0-4 hours) correlated reasonably with the full AUC (r = 0.87; P < .001). Finally, a significant reduction in CsA dose during the first 6 posttransplant months (P < .001) matched the significant increases in both MPA C0 and full MPA AUC, thus demonstrating the interaction of the 2 immunosuppressive drugs. These observations suggest the need for therapeutic drug monitoring when adjusting the dose of MMF in children.

Purpose: The nephropathy associated with vesicoureteral reflux (VUR) is one of the leading causes of chronic renal failure (CRF) in children. We describe the clinical course of the disease based on information available in the ItalKid Project database, and analyze the predictive value of baseline renal function, age at VUR diagnosis and urinary protein excretion in relation to the risk of progressive renal failure. Materials and Methods: As of December 31, 2001 the registry included a total of 343 patients (261 males) with a diagnosis of primary VUR, which was the leading single cause of CRF, accounting for 25.4% of all patients with CRF. Results: The estimated risk of end stage renal disease (ESRD) by age 20 years was 56%. The patients with a creatinine clearance (Ccr) of less than 40 ml per minute at baseline had an estimated 4-fold greater risk of ESRD developing in comparison with those whose Ccr was 40 to 75 ml per minute. No significant difference in probability of disease progression to ESRD was found between subjects diagnosed with VUR at age 6 months or less and those diagnosed later (older than 6 months). Furthermore, children with normal urinary protein excretion (a urinary protein [uPr]/urinary creatinine [uCr] ratio of less than 0.2 in 36 patients) and low grade proteinuria (uPr/uCr 0.2 to 0.8 in 34 patients) at baseline showed a significantly slower decrease in mean Ccr than those with moderate proteinuria (uPr/uCr greater than 0.8 in 34 patients). Hypertension and/or antihypertensive treatment (including antiprogressive drugs) were reported in 29.1% of patients. Conclusions: The results of the present study define the long-term risk of ESRD in a large population of children with CRF and VUR, and provide some critical information for identifying the prognosis.

Dear Editor,A 60-year-old man was admitted to the Emergency Roombecause of recurrent episodes of food regurgitation. Nohistory of alcohol or substance abuse was elicited and therewas no significant past medical history. Neurologicalexamination was unremarkable. He complained of dys-phagia, postprandial vomiting, sialorrhea and weight loss of10 kg over 5 months. Routine blood chemistry was normal.An oesophagogastroduodenoscopy showed oesophagealachalasia and the patient underwent Heller Myotomy withDor fundoplication. Two days post-surgery the patientdeveloped a paroxysmal neurological deterioration char-acterised by severe psychomotor agitation, confusion anddelirium with frank visual hallucinations. He was disori-entated in time, space, place and person and confabulat-ing. Retrograde, anterograde and semantic memory wereseverely impaired. He was unable to stand, had markedtruncal and limb ataxia and was incontinent of urine andfaeces. Deep tendon reflexes were normal in the upper limbsand absent in the lower limbs. There was an almost com-plete paralysis of the conjugate gaze with overt horizontalnystagmus and miotic, slowly reacting pupils. Cerebrospi-nal fluid (CSF) analysis revealed an increased cell count(10 cells/cm, all lymphocytes) and a mild increase in CSFprotein (75 mg/100 ml). MRI brain showed symmetricalaqueductal, thalamic, mamillary body and quadrigeminalhyperintensity on T2 weighted FLAIR sequences. On DWI(b = 1,000 s/mm

Little is known about the role of proteinuria in the progression of childhood renal diseases. We analyzed the decline in creatinine clearance ( C(Cr)) and kidney survival in 225 children (185 males) with chronic renal failure (CRF) due to isolated hypodysplasia or hypodysplasia associated with urological abnormalities. The data were based on the information available in the Italian Pediatric Registry of CRF (ItalKid Project), which includes patients from all of Italy aged20 years with C(Cr )levels of75 ml/min per 1.73 m(2). Patients aged2 years and those with C(Cr )levels of20 ml/min per 1.73 m(2) or a follow-up of1 year were excluded from the analysis, as were those receiving angiotensin-converting enzyme inhibitors. At baseline, the patients had a mean age of 7.8+/-4.2 years, a mean C(Cr )of 50+/-16.3 ml/min per 1.73 m(2), a median urinary protein/urinary creatinine (uPr/uCr) ratio of 0.38 (range 0.02-7.21), and a mean duration of follow-up of 3.5+/-1.1 years. The patients were divided into three groups on the basis of their baseline proteinuria levels: group A normal (uPr/uCr0.2) n=83; group B low (uPr/uCr 0.2-0.9) n=71; and group C mild (uPr/uCr0.9) n=71. Patients in groups A and B showed a significantly slower decline in C(Cr )than those in group C (slope +0.16+/-3.64 and -0.54+/-3.67 vs. -3.61+/-5.47, P0.0001) and a higher rate of kidney survival after 5 years (96.7% and 94.1% vs. 44.9%, P0.01). By multivariate analysis, the baseline uPr/uCr ratio ( P0.01) and age ( P0.0001) correlated with a faster decline in C(Cr )irrespective of baseline C(Cr). There was no correlation with mean arterial blood pressure. We conclude that proteinuria is an independent predictor of progression to end-stage renal failure also in children whose renal impairment is due to congenital hypodysplasia.