Search

BackgroundThis study evaluated the long-term effects of percutaneous intervention in children and adolescents with transplant renal artery stenosis (TRAS).MethodsTwenty patients had significant stenosis (>50%) and underwent percutaneous transluminal angioplasty (PTA/stenting) (TRAS group-intervention); 14 TNS (non-significant group -control) patients did not have significant stenosis (≤50%) and were treated clinically. The combined primary endpoints were death from all causes and late graft failure. The secondary endpoints were serum creatinine (SCr), systolic blood pressure (SBP), and diastolic blood pressure (DBP).ResultsNo statistically significant difference was found between TRAS-Intervention(N = 20) and TNS groups-Control (N = 14) for these clinical parameters: deaths, 1 (5.0%) vs. 0 (0.0%) (p = 1.000) and graft loss, 4 (20.0%) vs. 2 (14.3%) (p = 1.000). For the secondary endpoints, after 1 month and 1 year the values of SCr, SBP, and DBP were similar between the two groups but not statistically significant.DiscussionIn the TRAS group (intervention), the stent implantation was beneficial for treating refractory hypertension and reducing blood pressure (BP) in children and adolescents. Despite the outcomes being similar in the two groups, it can be inferred that the patients in the TRAS group (intervention) would have had a worse outcome without the percutaneous intervention.ConclusionTRAS treatment with stenting can be considered for children and adolescents. Because the sample in the present study comprised of only a specific population, further studies are needed for generalization.Trial registrationThe trial was registered at clinictrials.gov with trial registration number NCT04225338.

Abstract Background Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. Method This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. Results During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. Conclusion Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.

INTRODUCTION:Brazil ranks second in the absolute number of transplantations in the world. Despite improvements in graft survival, many patients will progress to graft loss and return to dialysis. Concerns exist regarding adverse clinical outcomes in this population when undergone peritoneal dialysis (PD). OBJECTIVE:To compare the occurrence of mortality, technique failure, and peritonitis among incident patients in PD coming from either Tx or pre-dialysis treatment. METHODOLOGY:A retrospective study in which 47 adult patients with Tx failure (Tx group) were matched for age, gender, diabetes mellitus (DM), modality and start year of PD, with 1:1 predialysis patient (nTx group). The Fine-Gray competing risk model was used to analyze mortality and technique failure. RESULTS:Compared to nTx, the Tx group had a lower body mass index, serum potassium, and albumin concentrations. A higher ferritin level, transferrin saturation and the number of patients with positive serology for viral hepatitis were also observed in the Tx group. In the multivariate analysis, patients of the Tx group had 4.4-times higher risk of death (p = 0.007), with infection as the main cause. Technique failure and peritonitis were similar in both groups. CONCLUSION:Previous Tx is a risk factor for mortality but not for technique failure or peritonitis in incident patients on a PD program.

INTRODUCTION:Thrombotic microangiopathy (TMA) in post-transplant setting has heterogeneous clinical manifestations. METHODS:We retrospectively studied data of 89 patients with post-transplant TMA, which was characterized by thrombi in at least one glomerulus and/or arteriole. Systemic TMA was defined by thrombocytopenia and microangiopathic anemia and early onset TMA, when occurred less than 90 days post transplant. RESULTS:The cumulative incidence was 0.93%. The majority of the recipients were young (mean age 39 years), female (52%) and Caucasian (48%) with primary kidney disease of unknown etiology (37%). Early TMA occurred in 51% of the patients and systemic TMA, in 25%. Underlying precipitating factors were: infection (54%), acute rejection (34%), calcineurin inhibitor toxicity (13%) and pregnancy (3%). 18% of the patients had several triggers. Glomerular TMA was observed in 50% of the biopsies and endothelial cell activation, in 61%. The 1-year patient survival was 97% and corresponding graft survival, 66%. Allograft survival was inferior when acute antibody mediated rejection (ABMR) occurred (with 41%; without 70%, p = 0.01), however no differences were determined by hemolysis, time of onset, thrombi location or endothelial cell activation. CONCLUSIONS:Our results suggest that post-transplant TMA is a rare but severe condition, regardless of its clinical and histological presentation, mainly when associated to ABMR.

BackgroundSevere Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection.Methodology/principal findingsThis was a retrospective, multicenter, case-control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5-965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05-18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2-7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001-1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46-2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83-35316.61).Conclusions/significanceSevere S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment.

Background: Hemodialysis (HD) is a life-saving treatment for patients with end stage renal disease. However, HD patients have markedly increased rates of cardiovascular morbidity and mortality. Previously, a link between the complement system and cardiovascular events (CV-events) has been reported. In HD, systemic complement activation occurs due to blood-to-membrane interaction. We hypothesize that HD-induced complement activation together with inflammation and thrombosis are involved in the development of CV-events in these patients.Methods: HD patients were followed for the occurrence of CV-events during a maximum follow-up of 45 months. Plasma samples were collected from 55 patients at different time points during one HD session prior to follow-up. Plasma levels of mannose-binding lectin, properdin and C3d/C3 ratios were assessed by ELISA. In addition, levels of von Willebrand factor, TNF-α and IL-6/IL-10 ratios were determined. An ex-vivo model of HD was used to assess the effect of complement inhibition.Results: During median follow-up of 32 months, 17 participants developed CV-events. In the CV-event group, the C3d/C3-ratio sharply increased 30 min after the start of the HD session, while in the event-free group the ratio did not increase. In accordance, HD patients that developed a CV-event also had a sustained higher IL-6/IL-10-ratio during the first 60 min of the HD session, followed by a greater rise in TNF-α levels and von Willebrand factor at the end of the session. In the ex-vivo HD model, we found that complement activation contributed to the induction of TNF-α levels, IL-6/IL-10-ratio and levels of von Willebrand factor.Conclusions: In conclusion, these findings suggest that early intradialytic complement activation predominantly occurred in HD patients who develop a CV-event during follow-up. In addition, in these patients complement activation was accompanied by a pro-inflammatory and pro-thrombotic response. Experimental complement inhibition revealed that this reaction is secondary to complement activation. Therefore, our data suggests that HD-induced complement, inflammation and coagulation are involved in the increased CV risk of HD patients.

Abstract Histoplasmosis is a fungus infection that mainly affects immunosuppressed patients. The authors present a case of a kidney transplant recipient who developed sepsis-like histoplasmosis, na atypical but severe manifestation of the disease. The fungus was found in blood and in a skin biopsy, and the treatment with liposomal amphotericin resulted in hepatotoxicity.

AbstractWe observed a case of recombinant human erythropoietin resistance caused by Gastric Antral Vascular Ectasia in a 40-year-old female with ESRD on hemodialysis. Some associated factors such as autoimmune disease, hemolysis, heart and liver disease were discarded on physical examination and complementary tests. The diagnosis is based on the clinical history and endoscopic appearance of watermelon stomach. The histologic findings are fibromuscular proliferation and capillary ectasia with microvascular thrombosis of the lamina propria. However, these histologic findings are not necessary to confirm the diagnosis. Gastric Antral Vascular Ectasia is a serious condition and should be considered in ESRD patients on hemodialysis with anemia and resistance to recombinant human erythropoietin because GAVE is potentially curable with specific endoscopic treatment method or through surgical procedure.

PURPOSE:To perform a cost analysis of simultaneous pancreas-kidney transplantation (SPKT) in a Brazilian hospital.METHODS: Between January 2008 and December 2011, 105 consecutive SPKTs at the Hospital of Kidney and Hypertension in Sao Paulo were evaluated. We evaluated the patient demographics, payment source (public health system or supplementary system), and the impact of each hospital cost component. The evaluated costs were corrected to December 2011 values and converted to US dollars.RESULTS: Of the 105 SPKT patients, 61.9% were men, and 38.1% were women. Eight patients died, and 97 were discharged (92.4%). Eighty-nine procedures were funded by the public health system. The cost for the patients who were discharged was $18.352.27; the cost for the deceased patients was $18.449.96 (p = 0.79). The FOR for SPKT during this period was positive at $5,620.65. The costs were distributed as follows: supplies, 36%; administrative costs, 20%; physician fees, 15%; intensive care unit, 10%; surgical center, 10%; ward, 9%.CONCLUSION: Mortality did not affect costs, and supplies were the largest cost component.

Introdução: O transplante renal é realizado em condições de urgência em uma população com elevado risco perioperatório. Instrumentos de avaliação de risco pré-transplante nesta população são escassos. Objetivo: Construir um escore com variáveis pré-transplante para estimar a probabilidade de sucesso do transplante renal, definido como sobrevida do receptor e do enxerto, com creatinina < 1,5 mg/dl no 6º mês. Métodos: Análise das variáveis de pacientes de um centro único e especializado em transplante renal em São Paulo. A regressão logística foi utilizada para construção da equação com as variáveis capazes de estimar a probabilidade de sucesso. Atribuímos pontos inteiros às variáveis para a construção do escore. Resultados: Dos 305 pacientes analisados, 176 (57,7%) atingiram o sucesso. Das 23 variáveis identificadas pela análise univariada, 21 foram incluídas no modelo de regressão logística e as 10 que se mantiveram independentemente associadas com o sucesso foram utilizadas na construção do escore. Quatro destas 10 variáveis eram socioeconômicas. Foi ótimo (área sob a curva ROC = 0,817) o poder de discriminação entre os grupos sucesso e não sucesso e adequado (teste de Hosmer e Lemeshow = 0,672) o grau de concordância entre as frequências das probabilidades estimadas pela equação e as frequências das probabilidades reais observadas. Houve correlação (0,982) entre as probabilidades estimadas via sistema de pontuação e regressão logística. Conclusão: O escore de pontos apresentado simplificou a estratificação do risco do candidato ao transplante conforme a probabilidade de sucesso. As variáveis socioeconômicas exerceram influência no sucesso, demonstrando a necessidade da criação de instrumentos prognósticos utilizando as variáveis clínico-demográficas da nossa população.

INTRODUÇÃO: A incidência de função tardia do enxerto (FTE) e função renal insatisfatória (FRI) após o transplante renal é significativamente maior no Brasil comparada com aquela observada nos Estados Unidos ou na Europa. Fatores relacionados ao doador falecido (DF) devem influenciar diretamente a ocorrência desses dois desfechos. OBJETIVO: Este estudo propõe-se a avaliar a influência das características do DF na incidência de FTE e FRI no Brasil. MÉTODOS: Variáveis clínicas e laboratoriais dos DF foram correlacionadas com a incidência de FTE e FRI. RESULTADOS: Foram avaliados 787 DF cujos órgãos foram transplantados em 1.298 pacientes. Notou-se elevada prevalência de uso de droga vasoativa (90,2%), hipernatremia (66,6%) e disfunção renal (34,8%). A incidência de FTE foi de 60,6% e de FRI foi de 55,2%. Considerando as características dos DF, observamos um aumento progressivo no risco de desenvolvimento de FTE para faixas etárias acima de 30 anos e a partir de tempo de isquemia fria (TIF) maior que 24 horas. O risco de FTE foi duas vezes maior em receptores de rim de doadores com creatinina sérica final (Cr) superior a 1,5 mg/dl. Hipertensão arterial (HA) e o TIF acima de 36 horas associou-se com aumentos de 82% e 99% no risco de FRI, respectivamente. A idade do doador acima de 40 anos associou-se com um aumento progressivo no risco de FRI. CONCLUSÃO: A idade, a função renal e a presença de hipertensão arterial no doador falecido, além do TIF prolongado, associaram-se com maior risco de FTE e FRI.

INTRODUÇÃO: Terapias de indução são usualmente utilizadas em receptores sensibilizados contra antígenos HLA, retransplantes e pacientes com risco de apresentar função tardia do enxerto (FTE). MÉTODO: Estudo retrospectivo com objetivo de avaliar os desfechos do transplante renal com doador falecido em pacientes que receberam indução com alentuzumabe (n = 9). Os pacientes do grupo controle, pareados conforme idade do receptor, tempo em diálise e tempo de isquemia fria, receberam timoglobulina (n = 18). RESULTADOS: Não houve diferença nas características demográficas entre os grupos. A idade média dos receptores foi de 47 anos e dos doadores, de 59 anos. Entre os doadores, 67% apresentavam critério expandido. A incidência de FTE foi de 55% e 56%, respectivamente. Ao final do primeiro ano, não houve diferença nas sobrevidas livre de rejeição aguda comprovada por biópsia (67,0% e 84,6%, p = 0,26), do paciente (83,3% e 81,2%; p = 0,63), do enxerto (62,5% e 66,7%; p = 0,82), do enxerto com óbito censorado (62,5% e 76,6%; p = 0,73) e na função renal (depuração de creatinina: 61,6 ± 18,2 versus 52,7 ± 26,1 mL/min, p = 0,503). Houve maior redução na contagem de linfócitos no sangue periférico no grupo alentuzumabe (dia 14:172 ± 129 versus 390 ± 195 N/mm³, p < 0,05; dia 30: 135 ± 78 versus 263±112 N/mm³, p < 0,05), porém com retorno mais rápido a valores normais após o transplante (dia 90: 683 ± 367 versus 282 ± 72 N/mm³, p < 0,05; dia 360: 1269 ± 806 versus 690±444 N/mm³, p < 0,05). O custo do tratamento com alentuzumabe foi de R$ 1.388,00, enquanto que o custo médio com timoglobulina foi de R$ 7.398,00. CONCLUSÃO: Essa experiência com alentuzumabe não demonstrou eficácia e/ou segurança superiores aos regimes com timoglobulina, apesar do custo ser em média cinco vezes menor.INTRODUCTION: Induction therapy has been used in sensitized patients, re-transplants, and in patients who have high risk to delayed graft function (DGF) after renal transplantation. METHODS: Retrospective study with aim to compare transplant endpoints between recipients of deceased donors which have received induction with alemtuzumab (n = 9) versus thymoglobulin (n = 18). Patients were matched for age, duration of dialysis treatment and cold ischemia time. RESULTS: There were no differences at demographic characteristics. All patients received kidney grafts from deceased donors and 67% of these donors met the expanded criteria. The incidence of DFG was similar in alemtuzumab and thymoglobulin groups, 55% and 56%. At 12 months, rates of rejection free survival (67% versus 89%, p = 0,13), graft survival (62,5% versus 76,6%; p = 0,73), graft with death censored (62,5% versus 76,6%; p = 0,82) and patient survival (83,3% versus 81,2%; p = 0,63) were similar between the two groups. Viral infections and renal function were similar between groups. At the end of the first month, alemtuzumab patients displayed a fewer lymphocyte number (135 ± 78 versus 263 ± 112 N/mm³, p < 0,05) followed by a more rapid recovery after 3 months (day 90: 683 ± 367 versus 282 ± 72 N/mm³; p < 0,05). Cost associated with alemtuzumab and thymoglobulin inductions therapies were R$ 1,388.00 and R$ 7,398.00. CONCLUSION: In this cohort of patients, alemtuzumab induction showed efficacy and safety comparable to thymoglobulin but with significant cost reduction.

INTRODUÇÃO: Sirolimo (SRL) é um imunossupressor com conhecida eficácia e perfil de segurança na profilaxia da rejeição aguda após o transplante renal. OBJETIVOS: Avaliar eficácia, tolerabilidade e segurança do uso do SRL e de prednisona em associação a ciclosporina (CSA) ou tacrolimo (TAC) após o transplante renal. METODOLOGIA: Estudo retrospectivo de 332 receptores de transplantes renais realizados entre 1999 e 2006. O desfecho primário foi a falha de tratamento, definida como a incidência cumulativa de rejeição aguda confirmada por biópsia (RACB), perda do enxerto, óbito ou descontinuação do SRL. RESULTADOS: Dos 332 transplantes, 92% foram com doador vivo. A média de idade dos receptores foi de 37 anos, sendo 65% homens, 46% brancos e 6% diabéticos. SRL foi associado a CSA ou TAC em 70,8% e 29,2% dos pacientes. A incidência de falha de tratamento foi de 22,2% e de 47,8% no final do primeiro e do quinto ano de transplante, sem diferença entre pacientes recebendo CSA ou TAC. Ao final do quinto ano, as sobrevidas do paciente, do enxerto, do enxerto censorando o óbito e livre de RACB foram de 92,8%, 86,1%, 92,7% e 82,2%, respectivamente. O tratamento com SRL foi interrompido em 27,1% dos pacientes: 22,9% em razão de reações adversas e 3,3% devido à ineficácia. Os principais motivos de suspensão do SRL foram dislipidemia (6,0%), disfunção do enxerto (5,2%), proteinúria (4,5%), infecções (1,5%), dificuldade de cicatrização (1,2%) e anemia (0,9%). CONCLUSÃO: Na população estudada, a eficácia e a segurança do SRL foram semelhantes quando combinado com CSA ou TAC. A tolerabilidade oral foi adequada considerando-se a relativa baixa taxa de interrupção do uso de SRL.INTRODUCTION: Sirolimus (SRL) is an immunosuppressive drug with confirmed efficacy and safety profile in the prophylaxis of acute rejection after renal transplantation. OBJECTIVES: To assess the efficacy, safety, and tolerability of SRL and prednisone in combination with cyclosporine (CSA) or tacrolimus (TAC) after renal transplantation. METHODS: Retrospective study of 332 renal transplant recipients from 1999 to 2006. Primary outcome included treatment failure, defined as the cumulative incidence of biopsy-proven acute rejection, graft loss, death, or SRL discontinuation. RESULTS: Living donors were the primary source of kidneys (92%). Regarding the recipients, mean age was 37 years, 65% were males, 46% were white, and the prevalence of diabetes was 6%. Sirolimus was combined with CSA and TAC in 70.8% and 29.2% of patients, respectively. Treatment failure rates at the first and fifth year of transplantation were 22.2% and 47.8%, respectively, without difference between the groups receiving CSA and TAC. At five years, the survival rates were as follows: patient's, 92.8%; graft's, 86.1%; deathcensored graft's, 92.7%; and free from biopsy-proven acute rejection, 82.2%. Treatment with SRL was discontinued in 27.1% of the patients, due to adverse effects (22.9%) and inefficacy (3.3%). The main reasons for SRL discontinuation were as follows: dyslipidemia (6%); graft dysfunction (5.2%); proteinuria (4.5%); infection (1.5%); delayed wound healing (1.2%); and anemia (0.9%). CONCLUSION: In this cohort of patients, SRL efficacy and safety were similar when combined with either CSA or TAC. Oral tolerability was adequate, considering the relatively low SRL discontinuation rate.

OBJETIVO: Avaliar a exeqüibilidade, a segurança e a acurácia diagnóstica do ecocardiograma sob estresse (EEDA) com dobutamina/atropina em candidatos a transplante renal. MÉTODOS: Pacientes candidatos a transplante renal com e sem nefropatia diabética realizaram EEDA e cineangiocoronariografia. Consideraram-se dois pontos de corte para doença arterial coronariana (DAC): > 50% e > 70% de obstrução de uma artéria epicárdica. RESULTADOS: Cento e quarenta e oito pacientes realizaram o EEDA e a angiografia coronariana. A média de idade foi de 52±9 anos, 69% eram do sexo masculino, 27% tinham nefropatia diabética, e 73%, HVE; 63% estavam assintomáticos, 36% e 22% apresentaram obstruções coronarianas > 50% e > 70%, respectivamente. A exeqüibilidade foi de 91% e houve 2,7% de complicações maiores. Obtiveram-se as seguintes médias de sensibilidade, especificidade e acurácia, considerando obstrução coronariana > 50%: 53% (IC:45-61), 87% (IC:81-93), e 75% (IC:63-83), respectivamente. Para obstrução >70%, 71% (IC:64-92), 85% (IC:79-91) e 81% (IC:75-87). A sensibilidade para diagnosticar doença uniarterial foi 41% (IC:19-63) e doença multiarterial, 78% (IC:64-92). CONCLUSÃO: O EEDA foi exeqüível e seguro; entretanto, foi ineficiente para rastreamento de DAC, considerando obstruções > 50%, mas pode ser útil para detecção de DAC em pacientes com obstruções > 70% e doença multiarterial.OBJECTIVE: To evaluate the feasibility, safety and accuracy of dobutamine/atropine stress echocardiography (DASE) for the detection of coronary artery desease (CAD) in renal transplant candidates. METHODS: Patients candidates to renal transplant were submitted consecutively to DASE and coronary angiography. The adopted angiographic criteria for CAD were an obstructive lesion of > 50% and > 70%. RESULTS: 148 patients underwent the DASE and the coronary angiography. Mean age was 52 ± 9 years, 69% of the patients were males; 27% had diabetic nephropathy and 73% had LVH; 63% were asymptomatic; 36% and 22% presented coronary obstructions > 50% and 70%, respectively. The DASE performance was 91% and major complication rate was 2.7%. The sensibility, specificity and accuracy for the diagnosis of coronary obstruction > 50% were 53% (CI:45-61), 87% (CI:81-93), and 75% (CI:63-83) respectively. For coronary obstruction > 70% these values were, respectively, 71% (CI:64-92), 85% (CI:79-91) and 81% (CI:75-87). The sensibility to detect univessel and multivessel disease was 41% (CI:19-63) and 78% (CI:64-92), respectively. CONCLUSION: The DASE was practical and safe; however, it presented a poor result for the detection of CAD regarding obstructions > 50%. It can be a useful screening for the detection of CAD in candidates with obstructions > 70% and multivessel disease.

OBJETIVO: avaliar as inter-relações recíprocas entre o transplante renal e a gravidez por meio da análise das intercorrências clínicas e obstétricas, bem como da investigação do desfecho perinatal. MÉTODOS: foi analisada série retrospectiva de 39 casos de gestação em 37 portadoras de transplante renal no período de janeiro de 1997 a dezembro de 2003. Foi criado um grupo controle composto por 66 grávidas sem doenças clínicas prévias, que freqüentaram pré-natal e deram à luz em 2002 e 2003. Esse grupo foi utilizado para possíveis comparações para as variáveis pré-eclâmpsia, ruptura prematura de membranas, prematuridade e crescimento intra-uterino restrito. Como características demográficas dos dois grupos foram relatados média de idade no momento da concepção, raça e os antecedentes obstétricos. Quanto às características do transplante relatamos o tipo de doador e o esquema imunossupressor utilizado. As variáveis clínicas estudadas foram hipertensão arterial crônica, anemia e infecção do trato urinário. As variáveis relativas ao transplante foram o intervalo entre a cirurgia e a concepção, a ocorrência de disfunção, rejeição e perda do enxerto. Quanto às variáveis obstétricas, analisamos a via de parto, a incidência de pré-eclâmpsia e a ruptura prematura de membranas. Entre os resultados perinatais consideramos a incidência de prematuridade e crescimento intra-uterino restrito. Relacionamos estes resultados aos níveis de creatinina das transplantadas renais no início do pré-natal. Para avaliação estatística foram utilizados os testes de chi2 e exato de Fisher. Em todos os casos, o nível de rejeição para a hipótese de nulidade foi sempre fixado em valor menor ou igual a 0,05 (5%). RESULTADOS: a média de idade das pacientes no momento da concepção foi de 27 anos. O doador vivo foi o tipo mais freqüente. Entre as drogas imunossupressoras, a ciclosporina foi a mais utilizada. Hipertensão arterial crônica foi observada em 82% dos casos, anemia em 77% e infecção do trato urinário em 38,5%. A incidência de disfunção do enxerto foi de 47,4%, tendo sido a pré-eclampsia a sua principal causa. Perda do transplante ocorreu em 10,2% dos casos. Quanto à via de parto, a cesariana foi realizada em 53,8%, tendo como principais indicações as síndromes hipertensivas. Pré-eclampsia ocorreu em 28,2% das transplantadas. Quanto aos resultados perinatais, prematuridade ocorreu em 46,1% dos casos, apresentando relação significativa com os níveis de creatinina maiores ou iguais a 1,5 mg/dL no primeiro trimestre. Outra intercorrência observada foi restrição de crescimento intra-uterino, verificada em 41,0% das gestações. A mesma não apresentou, entretanto, relação com os níveis séricos de creatinina. CONCLUSÕES: o grupo de estudo foi constituído por pacientes jovens. Hipertensão arterial crônica, anemia e infecção do trato urinário foram intercorrências clínicas bastante freqüentes. Disfunção do enxerto ocorreu em quase metade dos casos, devendo ser rastreada durante o pré-natal. Essas pacientes podem ainda evoluir para a perda do transplante, cujas causas podem ser obstétricas ou não. Quanto à via de parto, a cesariana teve incidência elevada, entretanto lembramos que a via de parto deve ser sempre de indicação obstétrica. Pré-eclampsia ocorreu de forma significativamente maior, devendo ser essas pacientes consideradas como condição de risco para essa complicação. Prematuridade e restrição de crescimento intra-uterino permanecem como importantes complicações perinatais, sendo que a prematuridade se relaciona com a função do transplante.PURPOSE: to evaluate the relationship between renal transplantation and pregnancy through the analysis of clinical and obstetric intercurrent events and perinatal outcomes. METHODS: a retrospective series of 39 cases of pregnancy in 37 women with renal transplantation from January 1997 to December 2003 was evaluated. A control group consisted of 66 pregnant women with no previous clinical pathologies. This group received prenatal care and these patients delivered during 2002 and 2003. Preeclampsia, premature rupture of membranes, premature delivery, and intrauterine growth restriction were used to compare these variables. Demographic characteristics of these groups were related to the mean age at conception, ethnic characteristics and obstetric past. Regarding renal transplantation the type of donator and used immunosuppressive drugs were evaluated. The studied clinical variables were chronic hypertension, anemia and urinary tract infection. The interval between the surgery and conception, occurrence of dysfunction, rejection and loss of the allograft were characteristcs related to the allograft. Obstetric variables were related to the type of delivery, incidence of preeclampsia and premature rupture of membranes. Perinatal outcomes were premature delivery and intrauterine growth restriction and these results were compared with renal function. The used statistical methods were the chi2 and Fisher's exact tests. The significance level was fixed always as less than or equal to 0.05 (5%). RESULTS: the mean age at conception was 27 years. The live donator was the most frequent among the patients. Among the immunosuppressive drugs, cyclosporine was the most used. Chronic hypertension occurred in 82% of the cases, anemia in 77% and urinary tract infection in 38.5%. The incidence of renal dysfunction was 47.4% and preeclampsia was the main cause. The loss of the renal transplantation occurred in 10.2%. Delivery by cesarean section was performed in 53.8% of the patients, and the main causes were hypertensive syndromes. Preeclampsia occurred in 28.2%. Among the perinatal outcomes, premature delivery occurred in 46.1% of the cases, with a significant relation to creatinine level greater than or equal to 1.5 mg/dL at the start of prenatal care. Another observed intercurrent event was intrauterine growth restriction, which occurred in 41.0%, and here we found no relation between this event and creatinine levels. CONCLUSIONS: young patients constituted the study group. Chronic hypertension, anemia and urinary tract infection were very common. Renal dysfunction was frequent and must be investigated during prenatal care. There were four cases of loss of the transplant due to clinical or obstetric causes. Cesarean delivery had the highest incidence, but vaginal delivery should be the first choice in these cases. Preeclampsia occurred very frequently and this complication should be considered as a high risk. Preterm delivery and intrauterine growth restriction were the main perinatal complications. Premature deliveries before 37 weeks of gestation were related to allograft function.

Tuberculosis is one of the most frequent opportunistic infections after renal transplantation and occurred in 30 of 1264 patients transplanted between 1976 and 1996 at Hospital São Paulo - UNIFESP and Hospital Dom Silvério, Brazil. The incidence of 2.4% is five times higher than the Brazilian general population. The disease occurred between 50 days to 18 years after the transplant, and had an earlier and worse development in patients receiving azathioprine, prednisone and cyclosporine, with 35% presenting as a disseminated disease, while all patients receiving azathioprine and prednisone had exclusively pulmonary disease. Ninety percent of those patients had fever as the major initial clinical manifestation. Diagnosis was made by biopsy of the lesion (50%), positivity to M. tuberculosis in the sputum (30%) and spinal cerebral fluid analysis (7%). Duration of treatment ranged from 6 to 13 months and hepatotoxicity occurred in 3 patients. The patients who died had a significant greater number of rejection episodes and received higher doses of corticosteroid. In conclusion, the administration of cyclosporine changed the clinical and histopathological pattern of tuberculosis occurring after renal transplantation.

INTRODUCTION: The growing number of renal transplant recipients in a sustained immunosuppressive state is a factor that can contribute to increased incidence of sepsis. However, relatively little is known about sepsis in this population. The aim of this single-center study was to evaluate the factors associated with hospital mortality in renal transplant patients admitted to the intensive care unit (ICU) with severe sepsis and septic shock. METHODS: Patient demographics and transplant-related and ICU stay data were retrospectively collected. Multiple logistic regression was conducted to identify the independent risk factors associated with hospital mortality. RESULTS: A total of 190 patients were enrolled, 64.2% of whom received kidneys from deceased donors. The mean patient age was 51 ± 13 years (males, 115 [60.5%]), and the median APACHE II was 20 (16-23). The majority of patients developed sepsis late after the renal transplantation (2.1 [0.6-2.3] years). The lung was the most common infection site (59.5%). Upon ICU admission, 16.4% of the patients had ≤ 1 systemic inflammatory response syndrome criteria. Among the patients, 61.5% presented with ≥ 2 organ failures at admission, and 27.9% experienced septic shock within the first 24 hours of ICU admission. The overall hospital mortality rate was 38.4%. In the multivariate analysis, the independent determinants of hospital mortality were male gender (OR = 5.9; 95% CI, 1.7-19.6; p = 0.004), delta SOFA 24 h (OR = 1.7; 95% CI, 1.2-2.3; p = 0.001), mechanical ventilation (OR = 30; 95% CI, 8.8-102.2; p

O diabetes mellitus é uma das principais etiologias da doença renal crônica no Brasil e no mundo. Nos pacientes que se encontram em estágio V de doença renal crônica, torna-se necessária a terapia renal substitutiva, que pode ser realizada através do transplante renal ou diálise. A diálise é a opção terapêutica com maior número de pacientes, apesar de ser a modalidade associada à menor sobrevida do paciente. As opções de transplante para paciente diabético são o transplante renal com doador vivo ou falecido ou transplante duplo de rim e pâncreas. O presente estudo teve como objetivo fazer uma revisão dos aspectos específicos do transplante renal em pacientes diabéticos, avaliar o impacto do transplante renal nas complicações crônicas do diabetes e, por fim, apresentar os resultados disponíveis na literatura que permitem avaliar qual a melhor modalidade de transplante para esses doentes. Com relação à avaliação pré-transplante, devido ao alto risco cardiovascular, a avaliação da doença arterial coronariana e doença arterial periférica devem ser realizadas de forma mais detalhada no paciente diabético. Além disso, o estudo das disfunções miccionais está indicado, devido à alta prevalência de bexiga neurogênica nesses pacientes. Em relação às complicações crônicas do diabetes, as evidências atuais sugerem que no transplante renal ocorre uma estabilização das lesões da retina na maioria dos pacientes, melhora na qualidade de vida, e melhora dos episódios de hipotensão postural e sintomas gastrointestinais. Em contrapartida, observa-se maior número de eventos cardiovasculares em comparação aos não-diabéticos e recidiva da nefropatia em porcentagem limitada dos casos. Com relação às modalidades de transplante disponíveis para o paciente diabético, os melhores resultados de sobrevida do paciente e do enxerto foram obtidos através da realização de transplante renal isolado com doador vivo ou com transplante duplo de rim e pâncreas, sendo o transplante renal isolado com doador falecido a modalidade associada aos piores índices de sobrevida, tanto do paciente quanto do enxerto.

The anatomical variations of renal veins observed during 342 nephrectomies in living donors are described, 311 cases on the left side and 31 on the right. The following anatomy of the renocava veins was observed: 1. On the left side the renal vein was always unique (311/311) and had two tributaries (suprarenal and gonadal veins) in 100 per cent and one or more renolumbar veins in 65.27 per cent, encircling the aorta in 1.07 per cent, was retroaortic in 1.4 per cent; and the inferior vena cava was double in 0.64 per cent; B- on the right side the renal vein was double in 29 per cent (9/31) and had only one tributary (gonadal vein) in one case, for 3.22 per cent (1/ 31); three or more renal veins in 9.7 per cent (3/31). We concluded that the left renal vein is always unique, presenting variations principally in its tributaries and trajectory. On the right side, the renal vein was double or triple in 38.79 per cent

OBJECTIVE: The ligation of the left renal vein (LLVR) in man is a contraversial procedure in view of the risks of lesion to the renal parenchyma. With the objective of studying the morphologic and functional alterations caused by these lesions, we conducted experimental research with rats. MATERIAL AND METHODS: 64 male adult EPM1-WISTAR rats were used, divided into 8 groups - 4 for LLRV and four for control. Each LLRV group and corresponding control group were sacrificed progressively on the 7th, 15th, 30th and 60th day after the initial surgery. RESULTS: We found morphofunctional alterations only in animals that underwent LLRV in the four periods of sacrifice.The proteinuria creatinine in serum, testosterone in serum and serum corticosterone in serum showed practically no alteration in relation to the normal values for rats. Statistically significant severe histological lesions were found in the kidneys and testes of the LLRV groups. Lesions in the suprarenal glands were also present in these groups, but no sufficient to demonstrate statistical significance CONCLUSION: Based on these results we can conclude that the ligation of the left renal vein is a procedure of high risk in these animals.

Abstract Mycobacterium tuberculosis infection in renal transplant recipients is associated with significant morbidity and mortality. Genitourinary tuberculosis is a less frequent presentation and a high level of suspicion is needed to avoid treatment delay. Management is challenging due to the interaction of calcineurin inhibitors with antituberculous medications and the known side effects of these drugs, with higher prevalence in this population. The authors present a case of a renal transplant recipient with urinary and constitutional symptoms whom is diagnosed with tuberculosis after a prostatic biopsy in an already disseminated stage and develops hepatotoxicity to antituberculous therapy.

ABSTRACT Solid organ transplantation is a significant development in the treatment of chronic kidney, liver, heart and lung diseases. This therapeutic approach has increased patient survival and improved quality of life. New surgical techniques and immunosuppressive drugs have been developed to achieve better outcomes. However, the variety of neurological complications following solid organ transplantation is broad and carries prognostic significance. Patients may have involvement of the central or peripheral nervous system due to multiple causes that can vary depending on time of onset after the surgical procedure, the transplanted organ, and the intensity and type of immunosuppressive therapy. Neurological manifestations following solid organ transplantation pose a diagnostic challenge to medical specialists despite extensive investigation. This review aimed to provide a practical approach to help neurologists and clinicians assess and manage solid organ transplant patients presenting with acute or chronic neurological manifestations.

ABSTRACT In 2004, a global spread of Chikungunya fever affected most tropical and subtropical regions of the world. In 2016, an outbreak occurred in Northeast Brazil with hundreds of cases documented. Solid organ transplant recipients have a modified immune response to infection and the clinical course is usually different from immunocompetent patients. The diagnosis can be challenging in this population. Most reports describe patients residing in endemic areas, although we must emphasize the importance of differential diagnosis in kidney transplanted travelers who visit endemic regions, such as Northeast Brazil. Here, we reported a case of a kidney transplant recipient that acquired Chikungunya fever after a trip to an endemic region at Northeast Brazil during the outbreak in 2016, with a good clinical evolution. We also present warning recommendations for travelers to endemic areas as additional measures to prevent disease outbreaks.

OBJECTIVES: To evaluate cardiovascular involvement in children and adolescents with End Stage Renal Disease (ESRD) and to characterize the main risk factors associated with this outcome. METHODS: Cross-sectional study of 69 children and adolescents at renal transplantation and 33 healthy individuals matched by age and gender. The study outcomes were left ventricular mass z-score (LVMZ) and carotid artery intima-media thickness (CIMT). The potential risk factors considered were age, gender, CKD etiology, use of oral vitamin D and calcium-based phosphate binders, systolic and diastolic blood pressure, body mass index z-score, time since diagnosis, dialysis duration, serum levels of ionic calcium, phosphorus, parathyroid hormone, fibroblast growth factor (FGF 23), uric acid, homocysteine, cholesterol, triglycerides, C-reactive protein (CRP), vitamin D and hemoglobin. RESULTS: In the multivariate analysis, the factors associated with LVMZ were dialysis duration, age, systolic blood pressure, serum hemoglobin and HDL cholesterol levels. Regarding CIMT, in the multivariate analysis, systolic blood pressure was the only factor associated with the outcome. CONCLUSION: Children exhibited important cardiovascular involvement at the time of the renal transplantation. Both of the studied outcomes were independently associated with systolic blood pressure. For this reason, controlling blood pressure seems to be the main therapy to minimize cardiovascular involvement in children with ESRD.