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Rev. Assoc. Med. Bras. (1992) ; 67(supl.1): 63-66, 2021. graf
Article in English | LILACS | ID: biblio-1287852


SUMMARY OBJECTIVE: This study aims to describe the result of the strategies adopted to maintain the transplant program amid the COVID-19 pandemic. METHODS: Since March 2020, several measures have been adopted sequentially, including the compulsory use of personal protective equipment and the real-time polymerase chain reaction testing of collaborators, symptomatic patients, potential deceased donors, candidates for recipients, and in-hospital readmissions, regardless of symptoms. The living-donor transplantation was restricted to exceptional cases. RESULTS: Among 1013 health professionals, 201 cases of COVID-19 were confirmed between March and August 2020, with no severe cases reported. In this period, we observed a 19% institutional increase in the number of transplants from deceased donors compared with that observed in the same period in 2019. There was no donor-derived severe acute respiratory syndrome virus (SARS-CoV-2) infection. Four COVID-19-positive patients underwent transplantation; after 28 days, all were alive and with functioning allograft. Among the 11,875 already transplanted patients being followed up, there were 546 individuals with confirmed diagnosis, 372 who required hospitalization, and 167 on mechanical ventilation, resulting in a 27% mortality rate. CONCLUSIONS: These data confirm that the adoption of sequential and coordinated measures amid the pandemic was able to successfully maintain the transplant program and ensure the safety of health professionals and transplanted patients who were already in follow-up.

Humans , Kidney Transplantation , COVID-19 , Living Donors , Pandemics , SARS-CoV-2
J. bras. nefrol ; 41(4): 575-579, Out.-Dec. 2019.
Article in English | LILACS | ID: biblio-1056614


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.

RESUMO Em 2004, um surto global de Chikungunya afetou a maioria das regiões tropicais e subtropicais do mundo. Em 2016, um surto ocorreu no Nordeste do Brasil com centenas de casos documentados. Receptores de transplantes de órgãos sólidos têm uma resposta imune modificada à infecção, e o curso clínico é geralmente diferente daquele em pacientes imunocompetentes. O diagnóstico pode ser desafiador nessa população. A maioria dos relatos descreve pacientes residentes em áreas endêmicas, embora devamos enfatizar a importância do diagnóstico diferencial em viajantes transplantados renais que visitam regiões endêmicas, como o Nordeste do Brasil. Aqui, nós relatamos o caso de um receptor de transplante renal que adquiriu febre Chikungunya após uma viagem a uma região endêmica no Nordeste do Brasil durante o surto de 2016, com uma boa evolução clínica. Também apresentamos recomendações de alerta para viajantes em áreas endêmicas, como medidas adicionais para prevenir surtos de doenças.

Humans , Female , Adult , Chikungunya virus/immunology , Kidney Transplantation/adverse effects , Chikungunya Fever/complications , Chikungunya Fever/therapy , Brazil/epidemiology , Chikungunya virus/genetics , Kidney Transplantation/methods , Treatment Outcome , Chikungunya Fever/diagnosis , Chikungunya Fever/immunology , Hospitalization , Immunosuppressive Agents/standards , Immunosuppressive Agents/therapeutic use
Braz. j. infect. dis ; 22(3): 193-201, May-June 2018. tab, graf
Article in English | LILACS | ID: biblio-974216


ABSTRACT Background In people living with HIV, much is known about chronic kidney disease, defined as a glomerular filtration rate under 60 mL/min. However, there is scarce data about prevalence and risk factors for milder impairment (60-89 mL/min). Objective The present study aims to assess the influence of sex, antiretroviral therapy, and classical risk factors on the occurrence of mild decreased renal function in a large Spanish cohort of HIV-infected patients. Methods Cross-sectional, single center study, including all adult HIV-1-infected patients under antiretroviral treatment with at least two serum creatinine measures during 2014, describing the occurrence of and the risk factors for mildly decreased renal function (eGFR by CKD-EPI creatinine equation of 60-89 mL/min). Results Among the 4337 patients included, the prevalence rate of mildly reduced renal function was 25%. Independent risk factors for this outcome were age older than 50 years (OR 3.03, 95% CI 2.58-3.55), female sex (OR 1.23, 95% CI 1.02-1.48), baseline hypertension (OR 1.57, 95% CI 1.25-1.97) or dyslipidemia (OR 1.48, 95% CI 1.17-1.87), virologic suppression (OR 1.88, 95% CI 1.39-2.53), and exposure to tenofovir disoproxil-fumarate (OR 1.67, 95% CI 1.33-2.08) or ritonavir-boosted protease-inhibitors (OR 1.19, 95% CI 1.03-1.39). Conclusions Females and patients over 50 seem to be more vulnerable to renal impairment. Potentially modifiable risk factors and exposure to tenofovir disoproxil-fumarate or ritonavir-boosted protease-inhibitors are present even in earlier stages of chronic kidney dysfunction. It remains to be determined whether early interventions including antiretroviral therapy changes (tenofovir alafenamide, cobicistat) or improving comorbidities management will improve the course of chronic kidney disease.

Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , HIV Infections/complications , HIV Infections/drug therapy , HIV Infections/epidemiology , Anti-HIV Agents/adverse effects , Kidney Failure, Chronic/etiology , Kidney Failure, Chronic/epidemiology , Spain/epidemiology , Comorbidity , Sex Factors , Prevalence , Cross-Sectional Studies , Risk Factors , Age Factors , Treatment Outcome , Statistics, Nonparametric , Risk Assessment , Viral Load , Antiretroviral Therapy, Highly Active/adverse effects , Glomerular Filtration Rate
J. bras. nefrol ; 38(4): 421-426, Oct.-Dec. 2016. tab
Article in English | LILACS | ID: biblio-829060


Abstract Introduction: Women regain fertility a few time after renal transplantation. However, viability of pregnancy and maternal complications are still unclear. Objective: To describe the outcomes of pregnancies in kidney transplanted patients, focusing on maternal complications. Methods: Retrospective study of pregnancies in kidney transplanted patients between 2004 and 2014, followed up 12 months after delivery. Each pregnancy was considered an event. Results: There were 53 pregnancies in 36 patients. Mean age was 28 ± 5years. Pregnancy occurred 4.4 ± 3.0 years post-transplant. Immunosuppression before conception was tacrolimus, azathioprine, and prednisone in 74% of the cases. There were 15% miscarriages in the 1st trimester and 8% in 2nd trimester. In 41% of the cases, it was necessary to induce labor. From all births, 22% were premature and 17% very premature. There were 5% stillbirths and 5% of neonatal deaths. De novo proteinuria occurred in 60%, urinary tract infection in 23%, preeclampsia in 11%, acute rejection in 6%, and graft loss in 2% of the cases. It was observed a significant increase in creatinine at preconception comparing to 3rd trimester and follow-up (1.17 vs. 1.46 vs. 1.59 mg/dL, p < 0.001). Conclusion: Although the sample is limited, the number of miscarriages was higher than in the general population, with high rates of maternal complications. Sustained increase of creatinine suggests increased risk of graft loss in long-term.

Resumo Introdução: Após o transplante renal, as mulheres recuperam a fertilidade em pouco tempo. Entretanto, a viabilidade da gestação e as complicações maternas da gravidez ainda são objeto de estudo. Objetivo: Descrever a evolução da gestação após o transplante renal, com foco principal nas complicações maternas. Métodos: Estudo retrospectivo de casos de gravidez ocorridos entre 2004 e 2014 em pacientes transplantadas renais, com seguimento de 12 meses após o parto. Cada gravidez foi considerada um evento. Resultados: Houve 53 gestações em 36 pacientes. A média de idade foi de 28 ± 5 anos. Gravidez ocorreu 4,4 ± 3 anos após o transplante. A imunossupressão preconcepção era composta de tacrolimo, azatioprina e prednisona em 74% dos casos. Houve 15% de aborto no 1º trimestre e 8% no segundo trimestre. Em 41% dos casos, foi necessário induzir o parto. De todos os nascimentos, 22% foram prematuros e 17% muito prematuros. Houve 5% de natimortos e de mortes neonatais. Proteinúria de novo ocorreu em 60%, infecção do trato urinário em 23%, pré-eclâmpsia em 11%, rejeição aguda em 6% e perda do enxerto em 2% dos casos. Foi observada elevação significante da creatinina quando comparados período preconcepção, 3º trimestre e pós-12 meses de seguimento (média de 1,17 vs. 1,46 vs. 1,59 mg/dl; p < 0,001). Conclusão: Os resultados demonstram taxa de aborto maior que na população em geral, com altas taxas de complicações maternas. Aumento sustentado da creatinina sugere aumento do risco de perda do enxerto em longo prazo.

Humans , Female , Pregnancy , Adult , Young Adult , Postoperative Complications/epidemiology , Pregnancy Complications/epidemiology , Pregnancy Outcome , Kidney Transplantation , Retrospective Studies
J. bras. nefrol ; 38(2): 225-233, tab, graf
Article in Portuguese | LILACS | ID: lil-787885


Resumo Introdução: Receptores de rim de doadores vivos HLA-idêntico apresentam menor risco para rejeição aguda e maior sobrevida do enxerto, quando comparado a outros tipos de transplante. Um regime imunossupressor sem inibidor de calcineurina (ICN) pode melhorar ainda mais esses resultados, através da redução de eventos cardiovasculares, metabólicos e tóxicos secundários a esse fármaco. Objetivo: Avaliar eficácia e segurança do novo tratamento imunossupressor com suspensão planejada do ICN. Métodos: Estudo prospectivo, aberto, braço único de tratamento em único centro para avaliar resultados do transplante renal HLA-idêntico em pacientes que recebem everolimo (EVR), tacrolimo (TAC) e corticoide, seguido da descontinuação do TAC 30 dias pós-transplante. Após análise interina de eficácia, a descontinuação do TAC foi postergada para o terceiro mês pós-transplante, através de emenda ao protocolo. Resultados: Trinta e nove pacientes foram incluídos. Apesar de as médias das concentrações de TAC e EVR terem respeitado os intervalos propostos, cinco pacientes tiveram rejeição aguda comprovada por biópsia e um paciente apresentou um episódio de glomerulite com depósitos de C4D. Esse resultado demandou o fim das inclusões. A proporção de pacientes com proteinúria > 0.5g/L não atingiu mais que 22% dos pacientes em nenhuma visita. Os eventos adversos mais frequentes foram relacionados ao uso de EVR: úlceras orais, dislipidemia e edema periférico. Conclusão: O regime proposto não foi eficaz para essa população, principalmente pela alta incidência de rejeição aguda. O perfil de segurança mostrou que a exposição prolongada a altas concentrações sanguíneas de EVR aumenta a incidência dos eventos adversos relacionados ao fármaco.

Abstract Introduction: Kidney transplant recipients from HLA-identical living donor have lower risk of acute rejection and greater graft survival compared to other types of kidney transplantation. Immunosuppressive regimens without calcineurin inhibitors (CNI) can further improve these results by reducing cardiovascular, metabolic and toxic events related to this drug class. Objective: This study aimed to evaluate efficacy and safety of a new immunosuppressive regimen with planned suspension of CNI. Methods: This was a prospective, single center and single treatment arm study to evaluate HLA-identical kidney transplant recipients receiving everolimus (EVR), tacrolimus (TAC) and corticosteroids, followed by TAC discontinuation 30 days after transplantation. TAC discontinuation was later postponed to the third month after an interim efficacy analysis. Results: Thirty-nine patients were included. Although mean TAC and EVR blood concentrations have remained within the proposed therapeutic ranges, five patients had biopsy-proven acute rejection and one patient had an episode of C4D-positive glomerulitis. This result led to the end of the inclusions. Interestingly, the proportion of patients with proteinuria greater than 0.5 g/L has not reached more than 22% of patients in any visit. Adverse events related to EVR use were the most incident in this population: oral ulcers, dyslipidemia and peripheral edema. Conclusion: The proposed scheme was not effective for this population, particularly due to a high incidence of acute rejection. Safety profile showed that prolonged exposure to a high concentration of blood EVR increases the incidence of adverse events related to this drug.

Humans , Male , Female , Adult , Kidney Transplantation , Everolimus/therapeutic use , Immunosuppressive Agents/therapeutic use , Histocompatibility Testing , Prospective Studies , Treatment Outcome , Living Donors
J. bras. nefrol ; 37(2): 212-220, Apr-Jun/2015. tab, graf
Article in Portuguese | LILACS | ID: lil-751458


Resumo Introdução: O número de pacientes idosos portadores de doença renal crônica aumenta progressivamente, desafiando os algoritmos de alocação, em um cenário de escassez de órgãos para transplante. Objetivo: Avaliar o impacto da idade sobre os resultados do transplante renal. Métodos: Foram analisados todos os 366 pacientes > 60 anos transplantados entre 1998-2010 versus um grupo controle de 366 pacientes mais jovens pareados por gênero, tipo de doador (vivo/falecido) e ano do transplante. Resultados: Diabetes mellitus (HR 1,5; IC 1,0-2,2; p = 0,031) e doador falecido (HR 1,7; IC 1,2-2,7; p = 0,013) se associaram independentemente a maior risco de óbito. Diabetes mellitus (HR 1,8; IC 1,2-2,6; p = 0,003) e priorização por acesso vascular (HR 2,9; IC 1,2-2,6; p < 0,001), mas não idade, foram fatores independentes de perda do enxerto renal. Conclusão: A idade avançada não teve impacto negativo no resultado do transplante quando excluído óbito do paciente como causa de perda do enxerto. A maior mortalidade entre a população senil esteve associada à maior frequência de comorbidades, em especial diabetes mellitus. .

Abstract Introduction: The number of elderly patients with chronic kidney disease increases progressively, challenging the allocation algorithms in a scenario of organ shortage for transplantation. Objective: To evaluate the impact of age on patient and graft survival. Methods: Evolution of all 366 patients greater than 60 years transplanted between 1998 and 2010 was analyzed versus a control group of 366 younger patients matched for gender, type of donor (living or deceased) and year of transplantation. Results: Diabetes mellitus (HR 1.8; IC 1.2-2.6; p = 0,003) and prioritization (HR 2.9; IC 1.2-2.6; p < 0,001), but not age, were independent factors for kidney graft loss. Conclusion: Advanced age was not related to negative outcomes after kidney transplantation, after excluding recipient death as a cause of allograft loss. Higher mortality rate in this group was associated to a higher frequency of comorbidities, especially diabetes mellitus. .

Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Young Adult , Kidney Transplantation , Age Factors , Cohort Studies , Graft Survival , Retrospective Studies , Time Factors , Treatment Outcome