Corticosteroid-free immunosuppression was feasible with the Bas/Tac and the Tac/MMF regimens. Both corticosteroid-free regimens were equally effective in preventing acute rejection, with the Bas/Tac therapy offering some safety benefits.

These data indicate autosomal dominant Alport syndrome as a disease with a low risk of ocular and hearing anomalies but with a significant risk to develop renal failure although at an older age than the X-linked form. We were unable to demonstrate a genotype-phenotype correlation. Altogether, these data make difficult the differential diagnosis with the benign familial haematuria due to heterozygous mutations of COL4A4 and COL4A3, especially in young patients, and with the X-linked form of Alport syndrome in families where only females are affected. A correct diagnosis and prognosis is based on a comprehensive clinical investigation in as many family members as possible associated with a broadly formal genetic analysis of the pedigree.

Italy was the first Western country to face the COVID-19 pandemic. Here we report the results of a national survey on kidney transplantation activity in February and March 2020, and the results of a three-round Delphi consensus promoted by four scientific societies: the Italian Society of Organ Transplantation, the Italian Society of Nephrology, the Italian Society of Anesthesia and Intensive Care, and the Italian Group on Antimicrobial Stewardship. All 41 Italian transplant centers were invited to express their opinion in the Delphi rounds along with a group of seven experts. The survey revealed that, starting from March 2020, there was a decline in kidney transplantation activity in Italy, especially for living-related transplants. Overall, 60 recipients tested positive for SARS-CoV2 infection, 57 required hospitalization, 17 were admitted to the ICU, and 11 died. The online consensus had high response rates at each round (95.8%, 95.8%, and 89.5%, respectively). Eventually, 27 of 31 proposed statements were approved (87.1%), 12 at the first or second round (38.7%), and 3 at the third (9.7%). Based on the Italian experience, we discuss the reasons for the changes in kidney transplantation activity during the COVID-19 pandemic in Western countries. We also provide working recommendations for the organization and management of kidney transplantation under these conditions.

Among 243 patients who received kidney transplants at our center, two patients suddenly developed a severe debilitating pain syndrome in the lower limbs. Case no. 1A 49-year-old male patient who received a deceased donor kidney transplant, in therapy with tacrolimus (plus steroids and perioperative basiliximab). One month after transplantation he reported joint pain in his ankles, knees, feet, and hands. The pain became so intense that the patient was forced to use crutches to walk. Clinical examination revealed intense pain at movement, without edema, redness, increase in temperature, or cutaneous trophic alterations. The patient was receiving tacrolimus 5 mg b.i.d. with levels between 5 and 10 ng/ml. There was no clinical or serologic evidence of rheumatic disease or rhabdomyolysis. The rise in serum creatinine was attributed to heavy non-steroidal antiinflamatory drug use. After withdrawing these agents, the serum creatinine decreased to 1.6 mg/dl. Bone radiographies showed osteoporosis at the heads of the knee, ankle, tarsal, and metatarsal bones. An ultrasound scan of the joints highlighted a minimal amount of articular effusion and a mild synovial reaction in the knee and foot joints. Magnetic resonance imaging (MRI) of the left knee showed an area of bone marrow edema in the external condyle of the femur and wearing of the cartilage (Figure 1). Computerized bone mineralometry showed a slight reduction of the bone mass, whereas bone scintigraphy revealed increased radionuclide uptake in the affected joints (Figure 2).

Higher rates of acute rejection early in treatment were seen with the steroid-free regimens, but this did not translate into poorer long-term outcomes, such as graft and patient survival and renal function. A trend for a more favorable cardiovascular risk profile was observed for steroid-free immunosuppression with Tac/Bas.