Use of sirolimus as an adjuvant therapy for kidney transplant recipients with high-risk cutaneous squamous cell carcinomas: a prospective non-randomized controlled study / Uso do sirolimo como terapia adjuvante para receptores de transplante renal com carcinoma espinocelular cutâneo de alto risco: um estudo prospectivo controlado não randomizado

ABSTRACT Introduction: Previous research demonstrated benefits of late conversion to mTOR inhibitors against cutaneous squamous cell carcinomas (cSCC) in kidney transplant recipients (KTR), despite of poor tolerability. This study investigated whether stepwise conversion to sirolimus monotherapy without an attack dose modified the course of disease with improved tolerability. Methods: This prospective exploratory study included non-sensitized KTR with more than 12-months post-transplant, on continuous use of calcineurin inhibitors (CNI)-based therapy, and with poor-prognosis cSCC lesions. Incidence densities of high-risk cSCC over 3-years after conversion to sirolimus-monotherapy were compared to a non-randomized group with high-risk cSCC but unsuitable/not willing for conversion. Results: Forty-four patients were included (83% male, mean age 60 ± 9.7years, 62% with skin type II, mean time after transplantation 9 ± 5.7years). There were 25 patients converted to SRL and 19 individuals kept on CNI. There was a tendency of decreasing density of incidence of all cSCC in the SRL group and increasing in the CNI group (1.49 to 1.00 lesions/patient-year and 1.74 to 2.08 lesions/patient-year, p = 0.141). The density incidence of moderately differentiated decreased significantly in the SRL group while increasing significantly in the CNI group (0.31 to 0.11 lesions/patient-year and 0.25 to 0.62 lesions/patient-year, p = 0.001). In the SRL group, there were no sirolimus discontinuations, no acute rejection episodes, and no de novo DSA formation. Renal function remained stable. Conclusions: This study suggests that sirolimus monotherapy may be useful as adjuvant therapy of high-risk cSCC in kidney transplant recipients. The conversion strategy used was well tolerated and safe regarding key mid-term transplant outcomes.

RESUMO Introdução: Pesquisas anteriores demonstraram benefícios da conversão tardia para inibidores de mTOR contra carcinomas espinocelulares cutâneos (CECs) em receptores de transplante renal (RTR), apesar da baixa tolerabilidade. Este estudo investigou se a conversão gradual para monoterapia com sirolimo sem dose de ataque modificou o curso da doença com melhor tolerabilidade. Métodos: Esse estudo prospectivo exploratório incluiu RTR não sensibilizados com mais de 12 meses pós-transplante, uso contínuo de terapia imunossupressora baseado em inibidor de calcineurina (CNI) associado a micofenolato de sódio ou azatioprina, com lesões de CECs de mau prognóstico. Comparou-se densidades de incidência de CECs de alto risco durante 3 anos após conversão para monoterapia com sirolimo à um grupo não randomizado com CECs classificados conforme os mesmos critérios de gravidade do grupo sirolimo, mas inadequado/não disposto à conversão. Resultados: Foram incluídos 44 pacientes (83% homens, idade média 60 ± 9,7 anos, 62% com fototipo de pele II, tempo médio pós-transplante 9 ± 5,7 anos). 25 pacientes foram convertidos para SRL e 19 indivíduos mantidos em CNI. Foi observado tendência de diminuição da densidade de incidência de todos CECs no grupo SRL e de aumento no grupo CNI (1,49 a 1,00 lesões/paciente-ano; 1,74 a 2,08 lesões/paciente-ano; p = 0,141). A densidade de incidência de lesões moderadamente diferenciadas diminuiu significativamente no grupo SRL enquanto aumentou significativamente no grupo CNI (0,31 a 0,11 lesões/paciente-ano; 0,25 a 0,62 lesões/paciente-ano; p = 0,001). No grupo SRL não houve descontinuação do sirolimo, nenhum episódio de rejeição aguda e nenhuma formação de DSA de novo. Função renal permaneceu estável. Conclusões: Esse estudo sugere que a monoterapia com sirolimo pode ser útil como terapia adjuvante de CECs de alto risco em RTR. A estratégia de conversão usada foi bem tolerada e segura em relação aos principais desfechos do transplante a médio prazo.

Estrategias de telesalud en la atención de personas con enfermedad renal crónica: revisión integradora / Telehealth strategies in the care of people with chronic kidney disease: integrative review / Estratégias de telessaúde no atendimento às pessoas com doença renal crônica: revisão integrativa

Objetivo: evaluar las evidencias sobre estrategias de telesalud en la atención de personas con enfermedad renal crónica. Método: revisión integradora de la literatura. La búsqueda de estudios primarios se realizó en seis bases de datos: PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, LILACS y Scopus. La muestra estuvo compuesta por 48 artículos publicados entre 2000 y 2021, la estrategia de telesalud fue aplicada mediante equipo multidisciplinario, médico, enfermero, farmacéutico, nutricionista y trabajador social. De los artículos se extrajo el tipo de estudio, país, estrategia aplicada, escenario, población y profesional. Los estudios fueron seleccionados mediante la lectura de título y resumen (fase 1) y, posteriormente, mediante la lectura completa (fase 2), se los categorizó por estrategia de telesalud. El resumen de resultados se presentó de forma descriptiva y los estudios se clasificaron según el nivel de evidencia. Resultados: el domicilio fue el más representativo en las terapias de diálisis y tratamiento conservador. Se identificaron seis categorías de estrategias de telesalud: dispositivos de monitoreo remoto, teleconsulta, plataforma digital, aplicaciones, estrategias multimodales y contacto telefónico. Conclusión: el uso de esas estrategias para la atención de personas con enfermedad renal crónica tiene diferentes formatos e implementaciones, las mismas son factibles para dicha población en cualquier etapa de la enfermedad y pueden ser aplicadas por diferentes profesionales de la salud especialmente en el ámbito domiciliario. La evidencia ha demostrado que la telesalud favorece la reducción de costos, la accesibilidad a ubicaciones remotas, un mejor seguimiento de la diálisis con resultados positivos sobre el control de los síntomas, la reducción de riesgos y capacitación del paciente.

Objective: to evaluate the evidence about telehealth strategies in caring for people with chronic kidney disease. Method: integrative literature review. The search for primary studies was carried out in six databases: PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, LILACS, and Scopus. The sample consisted of 48 articles published between 2000 and 2021. The telehealth strategy was applied by a multidisciplinary team of doctors, nurses, pharmacists, nutritionis, and social workers. The type of study, country, strategy applied, setting, population, and professional were extracted from the articles. The studies were selected by reading the title and abstract (phase 1) and then reading them in full (phase 2), categorizing them by telehealth strategy. The results were summarized descriptively and the studies were classified according to their level of evidence. Results: the home was the most representative in dialysis and conservative treatment. Six categories of telehealth strategies were identified: remote monitoring devices, teleconsultation, digital platforms, apps, multimodality strategies, and telephone contact. Conclusion: using these strategies for the care of people with chronic kidney disease presents different forms and implementations, being feasible for the renal population at any stage of the disease and applicable by different health professionals with an emphasis on the home environment. The evidence shows that telehealth favors lower cost, accessibility to remote locations, and better monitoring of dialysis with positive resul in symptom control, risk reduction, and patient training.

Objetivo: analisar as evidências sobre as estratégias de telessaúde no atendimento às pessoas com doença renal crônica. Método: revisão integrativa da literatura. A busca pelos estudos primários foi realizada em seis bases de dados: PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, LILACS e Scopus. A amostra foi composta por 48 artigos publicados entre 2000 e 2021, a estratégia de telessaúde foi aplicada por equipe multidisciplinar, médico, enfermeiro, farmacêutico, nutricionista e assistente social. Foram extraídos dos artigos o tipo de estudo, país, estratégia aplicada, cenário, população e profissional. Os estudos foram selecionados por leitura de título e resumo (fase 1) e, após, por leitura completa (fase 2), com sua categorização por estratégia de telessaúde. A síntese dos resultados foi apresentada de forma descritiva e os estudos classificados de acordo com o nível de evidência. Resultados: o domicílio foi o de maior representatividade nas terapias dialíticas e tratamento conservador. Foram identificadas seis categorias de estratégias de telessaúde: dispositivos de monitoramento remoto, teleconsulta, plataforma digital, aplicativos, estratégias multimodalidades e contato telefônico. Conclusão: a utilização dessas estratégias para o atendimento de pessoas com doença renal crônica apresenta diferentes formatos e implementações, sendo viável à população renal em quaisquer fases da doença e aplicável por diferentes profissionais de saúde com ênfase no ambiente domiciliar. As evidências apontaram que a telessaúde favorece a diminuição de custos, acessibilidade aos locais afastados, melhor monitoramento da diálise com resultados positivos no controle dos sintomas, redução dos riscos e treinamento do paciente.

Post kidney transplant infections with special reference to cytomegalovirus

Background: The burden of infectious disease is high among kidney transplant recipients because of concomitant immunosuppression. Methods: Study was a retrospective and prospective cohort study. The study was conducted for a period of 12 months and 30 transplant recipients were included. Results: Males comprised 86.66% of the study population. The mean age of the recipients was 37.96 years. UTI was the most common post-transplant infection observed in 15 patients (50%) of 30 patients. E. Coli infection was most predominant (50%) causing UTI. 5 patients (16.66%) in this study developed tuberculosis after renal transplantation. Two patients (6.66%) developed CMV infection in the study. Two patients (6.66%) developed COVID-19 infection in the study. Two patients (6.66%) developed herpes infection post-transplant. One patient (3.33%) in the study developed cryptococcal meningitis. One patient (3.33%) developed hepatitis C after 18 years of transplant. One patient (3.33%) developed hepatitis B after 10 years of transplant. Three patients (10%) developed lower respiratory tract infection and developed acute respiratory distress. Three patients (10%) had developed acute graft rejection within first year after transplantation. There are total of 13 deaths (43.33%) among 30 patients all of which were secondary to infections. Total of 4 patients among the 13 deaths had chronic graft rejection. Most common cause of death was tuberculosis (38.46%) followed by UTI (23%) and Lower respiratory tract infection (23%). Conclusions: The incidence of infections is relatively higher in kidney transplant recipients when compared to general populations due to immunosuppression.

Fatores associados ao tempo para realização do transplante renal pediátrico com doador falecido a partir da inscrição na lista de espera no estado do Rio de Janeiro / Factors associated with time to deceased donor pediatric kidney transplant for waitlisted children in Rio de Janeiro state

O transplante renal é a terapia de substituição renal com melhor sobrevida e qualidade de vida para crianças e adolescentes com falência de rins. O transplante de rins com doador falecido é a modalidade de transplante mais comumente realizada no Brasil e em muitos países. Este trabalho teve o objetivo de avaliar os fatores relacionados ao tempo até o primeiro transplante renal com doador falecido em crianças e adolescentes até 18 anos de idade a partir da inscrição na fila de espera para transplante renal. Foi realizado estudo retrospectivo com dados de crianças e adolescentes inscritas no cadastro técnico único (CTU) do sistema nacional de transplantes (SNT) referentes ao estado do Rio de Janeiro no período de 01/01/2012 a 30/06/2022. Foram realizadas análise de sobrevivência com eventos competitivos (transplante renal com doador vivo, remoção da lista e óbito) e regressão semiparamétrica de Cox. O estudo teve uma amostra de 296 crianças e adolescentes inscritos na lista de transplante renal, dos quais 75,6% transplantaram com doador falecido com tempo mediano de 112 dias. A maioria das crianças e adolescentes inscrita tinha entre 7 e 18 anos de idade (90%), era do sexo masculino (56%) e da raça/cor branca (45,6%), com PRA menor que 50% (96,6%), tipagem sanguínea A ou O (845), já havia transfundido (65,5%) e iniciado diálise antes de serem listados (86,1%). Um terço dos inscritos apresentava glomerulonefrite como doença de base. Na análise univariada, estar vinculado a centro transplantador com baixo volume de transplantes (HR 0,26 / IC 0,17-0,39), PRA ≥50% (HR 0,27 / IC 0,09-0,85) e idade entre 7 e 18 anos (HR 0,51 / IC 0,33-0,79) impactaram negativamente o tempo até o transplante renal com doador falecido. Ao passo que estar inscrito na época da pandemia de COVID-19 (HR 74 / IC 10,4-525) aumentou a probabilidade de transplantar com doador falecido. Já na análise múltipla, a oferta de rins (HR 1,01 / IC 1,003-1,03) e ter insuficiência renal crônica (HR 1,52 / IC 1,07-2,14) tiveram impacto positivo na probabilidade de receber transplante renal com doador falecido, enquanto PRA ≥50% (HR 0,17 / IC 0,05-0,56) e estar vinculado a centro de baixo volume (HR 0,67 / IC 0,45- 0,99) tiveram efeito negativo. Não se mostrou diferença em relação ao acesso ao transplante renal com doador falecido a partir da inscrição na fila de espera no que diz respeito a sexo, raça/cor, status socioeconômico, distância de moradia até o centro transplantador, tipagem sanguínea ou transfusão de sangue. Este estudo mostrou que o fator imunológico (PRA) e a característica do centro transplantador mostraram ser as únicas variáveis que impactaram o tempo até o transplante renal pediátrico com doador falecido mesmo quando controladas pelo efeito das outras variáveis.

Kidney transplantation offers better survival and quality of life than any other modality of kidney replacement therapy for children and teenagers with kidney failure. Deceased donor kidney transplant (DDKT) is the most frequent type of kidney transplant in Brazil and many countries. This work aims to evaluate the factors related to time until first DDKT in waitlisted children and teenagers up to 18 years old. In this retrospective study, data for kidney transplant waitlisted patients under 19 years old in Rio de Janeiro state was collected from the national transplant system of the Ministry of Health, from January 1 st , 2012, to June 30th , 2022. Survival analysis was performed with time to first DDKT as the outcome. Cox proportional hazards regression models with competing risks were also employed. Of the 296 waitlisted patients, 75,6% had DDKT with a median time of 112 days. Most of the waitlisted patients were between 7 and 18 years old (90%), male (56%) and white (45,6%). The majority had PRA of less than 50% (96,6%), blood type A or O (84%), had received blood transfusion (65,5%) and were on kidney replacement therapy (86,1%) before entering the waitlist. Glomerulonephritis was the cause of kidney disease in one third of the cases. In the univariate analysis, being listed by a low volume transplanting center (HR 0,26 / CI 0,17-0,39), PRA ≥50% (HR 0,27 / CI 0,09-0,85) and age between 7 and 18 years old (HR 0,51 / CI 0,33-0,79) had a negative impact on waitlist time to DDKT. Meanwhile, being listed during the COVID-19 pandemic (HR 74 / CI 10,4-525) increased the likelihood of undergoing a DDKT. Multivariable analysis confirmed the negative impact of PRA ≥50% % (HR 0,17 / CI 0,05-0,56) and being listed by a low volume transplanting center (HR 0,67 / CI 0,45-0,99) at the time of DDKT. On the hand, it was shown that the number of deceased donor kidneys (HR 1,01 / CI 1,003-1,03) and chronic kidney disease as cause of kidney failure (HR 1,52 / CI 1,07-2,14) increased the chance of DDKT. This work didn't show any difference in access to DDKT for waitlisted patients under 19 years old in terms of sex, race/skin color, socioeconomic status, distance between residence and transplanting center, blood type or blood transfusion. Finally, by accounting for clinical individual patient features and external factors, this study concluded that immunological status (PRA) and low volume transplanting centers were the only variables that impacted time to DDKT, even after controlling for covariables.

Immunosuppressive drugs in renal transplantation

A kidney transplant, sometimes known as a renal transplant, is the treatment of choice for kidney failure at end stage renal disease (ESRD). The renal transplant surgery is followed by a lifetime course of immunosuppressive agents, divided into initial induction phase and later maintenance phase. It is seen that the risk of acute rejection is maximum in the initial months after transplantation (induction phase) and then reduces later (maintenance phase). In induction phase there is use of high-intensity immunosuppression immediately after transplantation, when the risk of rejection is maximum and then the dose reduced for long- term therapy. The main challenge in the renal transplantation community is long- term transplant survival. Long-term graft loss is mainly due to acute and chronic graft rejection, and also due to complications of immunosuppressive therapy. Currently, there is triple therapy as conventional immunosuppressive protocol: a calcineurin inhibitor, an antimetabolite agent, and a corticosteroid. The main aim of development of new immunosuppressive agents is not only improvement of short- term outcomes but also to increase the long- term graft survival by less nephrotoxicity, and minimal side-effects.

Detección de ansiedad y depresión en el binomio receptor-donador durante el protocolo de trasplante renal / Anxiety and depression in the recipient-donor binomial during the kidney transplant protocol

ABSTRACT Introduction: Detection of anxiety and depression in the recipient-donor pair (BinRD) during the kidney transplant protocol (KT) is important to establish psychoeducational interventions that help achieve success during and after KT. Objective: To determine the presence of anxiety and depression symptoms in the BinRD during the RT protocol and to identify characteristics and associated factors. Methods: Cross-sectional study, including 174 binomials being evaluated for TR. The Beck Depression Scale (BDI-II) and the Hospital Anxiety and Depression Scale (HADS) were applied at the beginning of the RT protocol. Results: Anxiety and depression symptoms were more frequent in recipient candidates than in donors ([anxiety 39% vs 21%] [depression 46% vs 15%]) (p<0.0001). The recipients presented a higher risk of depression (OR=4.770, 95% CI 2.854-7.974, p<0.0001) and anxiety (OR=2.383, 95% CI 1.478-3.841, p<0.001). Undertaking hemodialysis in private units (OR 0.264, 95%CI 0.106-0.662, p=0.004) or being on automated peritoneal dialysis (OR 0.386, 95%CI 0.173-0.862, p=0.020 was associated with less anxiety in recipients. Conclusions: a high frequency of anxiety and depression symptoms in the BinRD, so it is important to offer effective psychological interventions focused especially on the recipient during the donation evaluation process.

RESUMEN Introducción: La detección de ansiedad y depresión en el binomio receptor-donador (BinRD) durante el protocolo de trasplante renal (TR) es importante, para establecer intervenciones psicoeducativas que ayuden a lograr el éxito durante y después del TR. Objetivo: Determinar presencia de síntomas de ansiedad y depresión en el BinRD durante el protocolo de TR e identificar características y factores asociados. Métodos: Estudio transversal, incluye 174 binomios en evaluación para TR. Se aplicó la Escala de Depresión de Beck (BDI-II) y la Escala de Ansiedad y Depresión Hospitalaria (HADS) al inicio del protocolo de TR. Resultados: Síntomas de ansiedad y depresión fueron más frecuentes en candidatos a receptores que en donadores ([ansiedad 39% vs 21%] [depresión 46% vs 15%]) (p<0.0001). Los receptores, presentaron mayor riesgo de depresión (OR=4.770, IC 95% 2.854-7.974, p<0.0001) y ansiedad (OR=2.383, IC 95% 1.478-3.841, p<0.001). Realizarse hemodiálisis en unidades privadas (OR 0.264, IC95% 0.106-0.662, p=0.004) o estar en diálisis peritoneal automatizada (OR 0.386, IC95% 0.173-0.862, p=0.020 se asoció a menor ansiedad en receptores. Conclusiones: Se evidenció una alta frecuencia de síntomas de ansiedad y depresión en el BinRD, por lo que es importante ofrecer intervenciones psicológicas eficaces enfocadas especialmente al receptor durante el proceso de evaluación para la donación.

Safety and efficacy of laparoscopy for acute appendicitis in kidney transplant recipients / 中华器官移植杂志

Objective:To explore the efficacy and safety of laparoscopy for acute appendicitis (AA)in kidney transplant(KT)recipients.Methods:From May 2016 to December 2022, retrospective review is conducted for 99 AA patients operated at Tianjin First Central Hospital.They are assigned into two groups of observation(kidney transplant recipients, 33 cases)and control(normal renal function patients, 66 cases). Laparoscopic perioperative data of white blood cell(WBC), neutrocyte percentage(NEUT%), C-reactive protein(CRP), procalcitonin(PCT), operative duration, intraoperative blood loss, postoperative drainage volume, postoperative hospitalization length, total hospitalization expense and morbidity of postoperative complications are compared.Results:After propensity score matching, no statistically significant inter-group difference existed in clinical profiles.WBC and NEUT% pre-operation are lower in observation group than those in control group[11.85(9.54~13.99)×10 9/L vs 13.74(12.42~14.66)×10 9/L, Z=-3.908, P<0.01; 85.00(73.65~89.60)% vs 88.20(83.85~90.20)%, Z=-2.522, P=0.012]. No significant inter-group difference existed in preoperative CRP/PCT(all P>0.05). No significant inter-group differences existed in WBC, NEUT, CRP or PCT at Day 3 post-operation(all P>0.05). No significant difference existed in creatinine level in observation group before and after operation( P>0.05). As compared with control group, operative duration was longer[86(74~99)vs 62(57~68)min, Z=-6.290, P=0.020], intraoperative blood loss greater[25(20~33)vs 15(15~20)ml, Z=-6.104, P<0.01], postoperative drainage volume larger[75(65~85)vs 35(25~36)ml, Z=-8.103, P<0.01], postoperative hospitalization time longer[7(6~9)d vs 5(4~5)d, Z=-7.064, P<0.01]and total hospitalization expense higher[(1.98±0.22)vs (1.73±0.22)ten thousand yuan, t=5.401, P<0.01]. No significant inter-group differences existed in time of postoperative passage of flatus( P=0.669). No significant inter-group difference existed in morbidity of postoperative complications( P=0.893). Conclusions:The efficacy of laparoscopic appendectomy in patients post-KT is basically comparable to that in counterparts with normal renal function.

Clinical applications, current challenges and future prospects of novel diagnostic biomarkers for kidney transplant rejection / 中华器官移植杂志

In recent years, rapid developments and wide applications of high-throughput omics technologies have greatly accelerated the discovery of novel biomarkers in the field of kidney transplantation(KT). Currently, several novel biomarkers for making an early diagnosis of KT rejection have successfully entered clinical practices with promising application values.As compared with such traditional parameters as glomerular filtration rate and proteinuria, these new biomarkers offer great advantages in diagnostic performance, specificity, non-invasiveness and dynamic monitoring.Meanwhile, these novel biomarkers also provide valuable insights into the pathogenesis and phenotyping of KT rejection.However, due to the limitations of inadequate representativeness of research samples and testing cost-effectiveness, these new biomarkers still face many hurdles during clinical applications.This review summarized the developments and applications of novel biomarkers for diagnosing KT rejection.Current difficulties and challenges were discussed based upon past research experiences.A precise diagnostic system for KT rejection shall be established in the future.

Clinical outcomes after treatment for NDM-producing Klebsiella pneumoniae infection after kidney transplantation / 中华器官移植杂志

Objective:To explore the clinical efficacy of ceftazidime/avibactam(CZA)plus aztreonam(ATM)for New Delhi metallo-β-lactamase(NDM)carbapenem-resistant Klebsiella pneumoniae(CRKP)infection after kidney transplantation.Methods:Clinical data are retrospectively reviewed for 11 RT recipients infected with NDM metallo-β-lactamase CRKP admitted into First Affiliated Hospital of Xi 'an Jiaotong University and Affiliated Renji Hospital of Shanghai Jiao Tong University from November 2018 to December 2019.Based upon treatment protocol, they are divided into two groups of ceftazidime/avibactam plus aztreonam(CZA-ATM, 5 cases)and other effective antibiotics(OAA, 6 cases).Age, gender, infection type, drug resistance gene, changes in body temperature and leucocyte count, treatment course and prognosis are summarized.Results:A total of 11 patients with NDM-producing CRKP infection after RT are recruited.There are seven males and four females with an age range of(19~66)(38.9±14.4)years.There are mixed pulmonary and urinary tract infections(3 cases), urinary tract infection(2 cases), pulmonary infection(1 case)and perirenal infection(5 cases).All isolates harbore NDM carbapenemase gene, 5 isolates carry Klebsiella pneumoniae carbapenemase(KPC)gene and 1 isolate contained both imipenemase metallo-β-lactamase(IMP)and verona integron-encoded metallo-β-lactamase(VIM)gene concurrently.Ceftazidime-avibactam plus aztreonam(CZA-ATM)is prescribed in five patients while the remainders receive OAA.No adverse reactions occurred in individuals on CZA-ATM and 2 cases on OAA have adverse reactions with a poor appetite and diarrhea.After 30-day infection, the curative cases of CZA-ATM and OAAs groups reach 4 and 5 respectively.No death occurred in neither groups at Day 30.And 90-day mortality is 0 and 1 respectively.Conclusions:For RT patients infected with NDM-producing CRKP, CZA-ATM combination therapy may be another effective treatment.

The use of intraoperative mannitol during the laparoscopic nephrectomy in living kidney donor and the prevention of delayed graft function / Uso de manitol intraoperatorio durante la nefrectomía por laparoscopia en donante vivo de riñón y la prevención de función retardada del injerto

Background and objectives: The administration of mannitol during laparoscopic hand-assisted nephrectomy in the living donor has been controversial with various recommendations about it. This study aims to evaluate the effect of the intraoperative mannitol in the living kidney donor and the incidence of delayed graft function (DGF). Methods: This study was a retrospective observational study with living kidney transplant recipients and donors who underwent laparoscopic hand-assisted nephrectomy at Colombiana de Trasplantes from January 2015 to September 2019. We assessed the impact of mannitol administration in living donors on the main transplant outcomes such as DGF, urinary volume, acute rejection, and mortality at 3 months of follow-up. We performed a descriptive analysis of demographics and clinical variables in our cohort. Results: A total of 367 recipients were evaluated. The incidence of DGF was 5.9% without mannitol versus 6.2% with mannitol (p = 0.99). The acute rejection episodes (12.2% without mannitol versus 4.7% with mannitol) had a trend difference between the comparative groups, but it was still not significant in the bivariate analysis (p = 0.06). The mortality rate in the recipient was not significant (p = 0.69). The mean serum creatinine did not have significant differences at 1 and 3 months of follow-up comparing both groups. Conclusion: The use of mannitol in living donors does not have a significant impact on the incidence of DGF in kidney recipients. A trend of association between mannitol administration and reduced acute rejection episodes was observed, though it was not statistically significant.

Antecedentes y objetivo: La administración de manitol durante la nefrectomía laparoscópica en el donante vivo ha sido discutida con diversas recomendaciones. El objetivo es evaluar la administración de manitol intraoperatorio en el donante vivo de riñón y la incidencia de función retardada del injerto en el receptor. Métodos: Estudio observacional retrospectivo con receptores de riñón y donantes vivos que tuvieron nefrectomía laparoscópica en Colombiana de Trasplantes entre enero de 2015 a septiembre de 2019. Evaluamos el impacto de administrar manitol en los principales desenlaces del trasplante: función retardada del injerto, volumen urinario, rechazo agudo y mortalidad del receptor a los 3 meses post-trasplante. Se realizó un análisis descriptivo de las características demográficas y clínicas. Resultados: Se evaluaron 367 receptores con una incidencia de función retardada del injerto de 5.9% sin manitol versus 6.2% con manitol (p = 0,99), el rechazo agudo (12,2% sin manitol versus 4,7% con manitol) tuvo una tendencia de diferencia entre ambos grupos no significativa (p = 0,06) y la mortalidad del receptor tampoco mostró diferencias significativas (p = 0,69). La media de creatinina sérica al mes y 3 meses no tuvo diferencias significativas en los grupos. Conclusión: El uso de manitol en los donantes vivos de riñón no impactó significativamente la incidencia de función retardada del injerto en los receptores de trasplante. Se encontró una tendencia de asociación en la administración de manitol intraoperatorio y la reducción de los episodios de rechazo agudo al tercer mes post-trasplante en los receptores. No obstante, esta tendencia no tuvo la suficiente relevancia estadística.

Real-world effectiveness and safety of direct-acting antivirals for the treatment of hepatitis C virus in kidney and liver transplant recipients: experience of a large transplant center in Brazil

ABSTRACT Direct-acting antivirals are the gold-standard treatment for chronic HCV infections, but few studies have investigated their use on kidney and liver transplant recipients. We conducted a real-world study to evaluate the rates of sustained virological response with direct-acting antivirals in kidney and liver transplant recipients. Moreover, it also aimed to evaluate direct-acting antivirals (DAAs) interference with immunosuppressant levels and to describe the frequency of adverse events. As part of this retrospective observational cohort, we included adult patients that had undergone a kidney transplant (KT) or liver transplant (LT) at our center, had a chronic HCV infection, and were treated with DAAs from June 2016 to December 2021. A total of 165 patients were included in the analysis, divided in 108 KT and 57 LT recipients. HCV genotype 1 was more frequent in KT (58.4%), and genotype 3 was more prevalent in LT (57.9%) patients. Sustained virological response was achieved in 89.6% of patients. Adverse effects were reported by 36% of patients. There were significant interactions with immunosuppressants requiring dose adjustments. A total of three episodes of rejection were reported in KT recipients. In conclusion, DAA treatment resulted in high rates of SVR and was well tolerated in both kidney and liver transplant patients. Adverse events were frequent but not severe in most patients, with low treatment drop-out rates. Interactions with immunosuppressants need monitoring since dose adjustments may be required. Reporting real-life experiences is important to help build evidence for patient management in non-controlled environments.

Resultados de la anestesia total intra venosa (TIVA) con perfusión controlada por objetivo (TCI) en pacientes sometidos a trasplante renal / Outcomes of Total Intravenous Anesthesia (TIVA) with Goal Controlled Perfusion (TCI) in Kidney Transplant Patients

Introducción: La anestesia total intravenosa (TIVA) con perfusión controlada por objetivo (TCI) es una técnica de anestesia general que usa una combinación de fármacos administrados exclusivamente por vía intravenosa sin usar fármacos por vía inhalatoria. Objetivos: Determinar los resultados del uso de TIVA TCI en los pacientes sometidos a trasplante renal, donantes y receptores, entre noviembre de 2014 y julio de 2018, en el Hospital de Clínicas. Pacientes y métodos: Estudio observacional, analítico transversal, con muestreo no probabilístico a criterio. La serie se agrupó en donantes y receptores. Los datos se expresan en medias y proporciones, se analizó el Odds Rattio y el R2. Se consideró una p< 0,05 como significativa. Resultados: se incluyeron a 198 intervenciones anestésicas, 131 (66,2%) fueron receptores. El rango de edad fue de entre 5 y 66 años (35,8±13 años) y 114 (57%) fueron masculinos. En el post operatorio inmediato, el tiempo en despertar, la PAS, PAD, PAM, frecuencia cardiaca y saturación de oxígeno no tuvieron diferencias significativas, en la comparación de los grupos (donante y receptor). Se observó cefalea en 3 (1,5%) del grupo de donantes y ninguna en los receptores. La diuresis fue tardía en 18 (9,1%) pacientes (p= 0,084 R2=29). Conclusión: La TIVA TCI demostró ser una técnica muy efectiva en el trasplante renal, con pronta recuperación y despertar inmediato tras la extubación, con lucidez absoluta en todos los pacientes.

Introduction: Total intravenous anesthesia (TIVA) with goal-controlled perfusion (TCI) is a general anesthesia technique that uses a combination of drugs administered exclusively intravenously without using inhalational drugs. Objectives: To determine the results of the use of TIVA TCI in kidney transplant patients, donors and recipients, between November 2014 and July 2018, at the Hospital de Clínicas. Patients and methods: Observational, cross-sectional analytical study, with non-probabilistic sampling at the discretion. The series was grouped into donors and recipients. The data is expressed in means and proportions, the Odds Rattio and the R2 were analyzed. A p<0.05 was considered significant. Results: 198 anesthetic interventions were included, 131 (66.2%) were recipients. The age range was between 5 and 66 years (35.8±13 years) and 114 (57%) were male. In the immediate postoperative period, time to awakening, SBP, DBP, MAP, heart rate and oxygen saturation did not show significant differences when comparing the groups (donor and recipient). Headache was observed in 3 (1.5%) of the donor group and none in the recipients. Diuresis was late in 18 (9.1%) patients (p= 0.084 R2=29). Conclusion: TIVA TCI proved to be a very effective technique in kidney transplantation, with prompt recovery and immediate awakening after extubation, with absolute clarity in all patients.

Direct costs associated with lupus nephritis management in the Private Healthcare System in Brazil: an expert panel perspective / Custos diretos associados ao manejo da nefrite lúpica no Sistema de Saúde Privado no Brasil: uma perspectiva segundo painel de especialistas

Objective: To estimate direct medical costs of lupus nephritis (LN) in the Brazilian private healthcare system. Methods: An expert panel of five specialists were convened to discuss health resource usage in LN patient management. The discussion included diagnosis, treatment, and disease monitoring, including dialysis and kidney transplantation. Unit costs (in BRL) were obtained from public sources, and an estimation of 1-year costs was conducted. Results: Approximately 76.0% of patients with LN undergo kidney biopsy, of which 48.1% present with LN classes III­IV and 21.4% have class V. Around 67.5% of patients with LN classes III­IV experience an average of four renal flares annually. Overall, 20.3% of patients present refractory LN, and 10.3% have end-stage kidney disease (ESKD), requiring dialysis and kidney transplantation. Estimated total weighted annual costs per patient were BRL 115,824.81 for LN classes III­IV, BRL 85,684.79 for LN class V, BRL 115,594.98 for refractory LN; and BRL 325,712.88 for ESKD. The main annual cost driver for LN classes III­IV was renal flares (BRL 60,240.41; 52.0%) and dialysis for LN class V (BRL 31,128.38; 36.3%). Conclusions: Total direct costs increase when LN progresses to ESKD. Although it is challenging to improve the diagnosis, identification of the disease at an early stage, together with rapid initiation of treatment, are fundamental elements to optimize results, potentially reducing costs to the system and the impact of disease burden and quality of life on patients.

Objetivo: Estimar os custos médicos diretos da nefrite lúpica (NL) no sistema suplementar de saúde brasileiro. Métodos: Um painel de cinco especialistas foi estruturado para discutir o uso de recursos em saúde no manejo de pacientes com NL. Nesta discussão, incluíram-se o diagnóstico, o tratamento e o monitoramento da doença, contemplando também diálise e transplante renal. Os custos unitários foram obtidos de fontes públicas e os resultados expressos em custo anual. Resultados: Aproximadamente 76,0% dos pacientes com NL são submetidos à biópsia renal, sendo 48,1% com NL de classes III-IV e 21,4% de classe V. Cerca de 67,5% dos pacientes com classes III-IV apresentam, aproximadamente, quatro flares renais anuais. No geral, 20,3% dos pacientes apresentam NL refratária e 10,3% desenvolvem doença renal terminal (DRT), necessitando de diálise e transplante renal. O custo ponderado anual estimado por paciente foi de R$ 115.824,81 para NL de classes III-IV, R$ 85.684,79 para classe V, R$ 115.594,98 para NL refratária e R$ 325.712,88 para DRT. O principal fator para incremento dos custos anuais para NL de classes III-IV foram os flares renais (R$ 60.240,41; 52,0%) e, na classe V, a diálise (R$ 31.128,38; 36,3%). Conclusões: Há um incremento dos custos diretos da NL na progressão para DRT. Embora seja desafiador melhorar o diagnóstico, a identificação da doença em uma fase precoce, aliada ao tratamento iniciado de forma célere, são elementos fundamentais para otimizar os resultados, potencialmente reduzindo os custos ao sistema e o impacto da carga da doença e qualidade de vida dos pacientes.

Aplicabilidade da teoria da incerteza da doença na lista de espera de transplante renal / Aplicabilidad de la teoría de la incertidumbre de la enfermedad en la lista de espera de trasplante renal / Applicability of the uncertainty in illness theory on patients on kidney transplant waiting lists

Objetivo: Apreender as experiências da vida cotidiana de pessoas em lista de espera de transplante renal e verificar a aplicabilidade da Teoria da Incerteza da Doença nesse contexto. Método: Pesquisa exploratória, descritiva de abordagem qualitativa, interpretada à luz da Teoria da Incerteza da Doença, de Merle Mishel. Resultados: Emergiram, da análise do conteúdo das entrevistas de oito pacientes, dois eixos significativos, denominados Aspectos internos do ajustamento à condição da doença e Aspectos externos do ajustamento à condição da doença que abrangem as categorias nomeadas de adaptação, enfrentamento, fornecedores de estrutura, quadro de estímulos e nova perspectiva de vida. Conclusão: O estudo possibilitou aprender os sentimentos preponderantes nas vivências das pessoas em lista de espera de transplante, as relações interpessoais com os familiares e equipe de saúde, o enfrentamento da doença e a esperança de um órgão compatível, assim como a aplicabilidade da Teoria no contexto do transplante renal.

Purpose: To understand the daily experiences of people on a kidney transplant waiting list and to verify the applicability of the Uncertainty in Illness Theory in this context. Method: An exploratory, descriptive, and qualitative research, based on Merle Mishel's Theory of Uncertainty in Illness. Results: From the analysis of interviews with eight patients, two significant axes emerged: a) Internal aspects of adjustment to the condition of the disease; and b) External aspects of adjustment to the condition of the disease. These axes cover the categories "adaptation", "coping", "structure providers", "stimulus board" and "new life perspectives". Conclusion: The study made it possible to understand the predominant feelings of people on a transplant waiting list, in addition to learning about their interpersonal relationships with family members and the health team, their coping with the disease, and their hope for a compatible organ. It was also possible to understand the applicability of the Theory in the context of a kidney transplant.

Objetivo: Conocer las vivencias de la vida diaria de las personas en lista de espera de trasplante renal y verificar la aplicabilidad de la Teoría de la Incertidumbre de la Enfermedad en este contexto. Método: Investigación cualitativa descriptiva exploratoria, interpretada a la luz de la Teoría de la Incertidumbre de la Enfermedad de Merle Mishel. Resultados: Del análisis del contenido de las entrevistas de ocho pacientes surgieron dos ejes significativos denominados Aspectos internos de ajuste a la condición de la enfermedad y Aspectos externos de ajuste a la condición de la enfermedad, que abarcan las categorías denominadas adaptación, afrontamiento, proveedores de estructura, relación de estímulos y nueva perspectiva de vida. Conclusión: El estudio permitió conocer los sentimientos predominantes en las vivencias de las personas en lista de espera de trasplante, las relaciones interpersonales con los familiares y el equipo médico, el afrontamiento de la enfermedad y la esperanza de un órgano compatible, así como la aplicabilidad de la Teoría en el contexto del trasplante de riñón.

Migratory pattern of the coronavirus disease 2019 and high fatality rates among kidney transplant recipients: report from the Brazilian Multicenter Cohort Study / Padrão migratório da doença coronavírus 2019 e altas taxas de mortalidade entre receptores de transplante renal: relatório do Estudo de Coorte Multicêntrico Brasileiro

Abstract Introduction: The unprecedented coronavirus disease 2019 (COVID-19) pandemic has affected kidney transplant (KT) recipients, with worldwide fatality rates around 25%. Considering the well-known Brazilian socio-demographic disparities, this report describes for the first time the main outcomes of COVID-19 in KT recipients according to Brazilian geographic regions. Methods: This multicenter national retrospective analysis included data from KT recipients with confirmed COVID-19 between March and November 2020. Results: Thirty-five of the 81 centers (57% of KT activity in Brazil) reported 1,680 patients with COVID-19. The Northeast was the first to reach the peak in the number of infections. The Southeast, due to its population density, contributed with the largest number of patients. Patients had a median age of 52 years, 76% had hypertension and 34% diabetes, 75% were recipients of a deceased donor, and the time interval between diagnosis and transplantation was 5.9 years. In 53% of patients, immunosuppression was adjusted, and clinical support varied according to geographic region. Hospitalization was required for 65% of the patients, 35% of them needed intensive care, 25% mechanical ventilation, and 23% renal replacement therapy. The 90-day overall fatality was 21%, being 23% in the Southeast, 16% in the Northeast, and 19% in the Central-west and South regions. Conclusion: The migratory pattern of the pandemic among KT recipients followed that of the general population and the outcomes were influenced by regional features. COVID-19 in KT recipients was associated with high utilization of health-care resources and higher fatality rates than those reported in the general population.

Resumo Introdução: A pandemia da COVID-19 afetou receptores de transplante renal (TR), com taxas de mortalidade mundial em torno de 25%. Considerando as notórias disparidades sócio-demográficas brasileiras, este relatório descreve pela primeira vez principais características e desfechos da doença em receptores de TR, segundo as regiões geográficas. Métodos: Esta análise retrospectiva multicêntrica nacional incluiu dados de receptores de TR com COVID-19 confirmada entre Março/Novembro de 2020. Resultados: Trinta e cinco dos 81 centros (57% da atividade de transplante renal brasileira) relataram 1.680 pacientes com COVID-19. O Nordeste foi o primeiro a atingir o pico no número de infecções. O Sudeste, por sua densidade populacional, contribuiu com maior número de pacientes. Pacientes tinham em média 52 anos, 76% apresentavam hipertensão e 34% diabetes, 75% receptores de doador falecido e o tempo entre diagnóstico e transplante foi de 5,9 anos. Em 53% dos pacientes, os imunossupressores foram ajustados, e o tratamento variou segundo a região. Hospitalização foi necessária para 65% dos pacientes, 35% necessitaram de cuidados intensivos, 25% ventilação mecânica, e 23% terapia renal substitutiva. A mortalidade geral em 90 dias foi 21%, sendo 23% no Sudeste, 16% no Nordeste, e 19% nas regiões Centro-Oeste e Sul. Conclusão: O padrão migratório da pandemia entre os receptores de TR seguiu o da população em geral e os desfechos foram influenciados por características regionais. A COVID-19 em receptores de TR foi associada à alta utilização de recursos de saúde e taxas de mortalidade mais altas do que as relatadas na população em geral.

Predictive ability of severity scores and outcomes for mortality in kidney transplant recipients with coronavirus disease 2019 admitted to the intensive care unit: results from a Brazilian single-center cohort study / Capacidade preditiva de escores de gravidade e desfechos para mortalidade em receptores de transplante renal com COVID-2019 admitidos em unidade de terapia intensiva: resultados de um estudo de coorte brasileiro de um único centro

Abstract Background: the predictive ability of severity scores for mortality in patients admitted to intensive care units is not well-known among kidney transplanted (KT) patients, especially those diagnosed with coronavirus disease 2019 (COVID-19). The purpose of the present study was to evaluate the predictive ability of severity scores for mortality in KT recipients. Methods: 51 KT recipients with COVID-19 diagnosis were enrolled. The performance of the SOFA, SAPS 3, and APACHE IV tools in predicting mortality after COVID-19 was compared by the area under the ROC curve (AUC-ROC) and univariate Cox regression analysis was performed. Results: The 90-day cumulative incidence of death was 63.4%. Only APACHE IV score differed between survivors and nonsurvivors: 91.2±18.3 vs. 106.5±26.3, P = 0.03. The AUC- ROC of APACHE IV for predicting death was 0.706 (P = 0.04) and 0.656 (P = 0.06) at 7 and 90 days, respectively. Receiving a kidney from a deceased donor (HR = 3.16; P = 0.03), troponin levels at admission (HR for each ng/mL = 1.001; P = 0.03), APACHE IV score (HR for each 1 point = 1.02; P = 0.01), mechanical ventilation (MV) requirement (HR = 3.04; P = 0.002) and vasopressor use on the first day after ICU admission (HR = 3.85; P < 0.001) were associated with the 90-day mortality in the univariate analysis. Conclusion: KT recipients had high mortality, which was associated with type of donor, troponin levels, early use of vasopressors, and MV requirement. The other traditional severity scores investigated could not predict mortality.

RESUMO Introdução: a capacidade preditiva dos escores de gravidade para mortalidade em pacientes admitidos em unidades de terapia intensiva não é bem conhecida entre pacientes transplantados renais (TR), especialmente aqueles diagnosticados com doença coronavírus 2019 (COVID-19). Este estudo avaliou a capacidade preditiva dos escores de gravidade para mortalidade em receptores de TR. Métodos: Foram inscritos 51 receptores de TR diagnosticados com COVID-19. O desempenho das ferramentas SOFA, SAPS 3, APACHE IV em predizer mortalidade após COVID-19 foi comparado pela área sob a curva ROC (AUC-ROC) e realizou-se análise de regressão univariada de Cox. Resultados: A incidência cumulativa de óbito em 90 dias foi 63,4%. Somente APACHE IV diferiu entre sobreviventes e não-sobreviventes: 91,2±18,3 vs. 106,5±26,3; P = 0,03. A AUC-ROC do APACHE IV para predizer óbito foi 0,706 (P = 0,04) e 0,656 (P = 0,06) aos 7 e 90 dias, respectivamente. Receber rim de doador falecido (HR = 3,16; P = 0,03), níveis de troponina na admissão (HR para cada ng/mL = 1,001; P = 0,03), escore APACHE IV (HR para cada 1 ponto = 1,02; P = 0,01), necessidade de ventilação mecânica (VM) (HR = 3,04; P = 0,002), uso de vasopressor no primeiro dia após admissão na UTI (HR = 3,85; P < 0,001) foram associados à mortalidade em 90 dias na análise univariada. Conclusão: Receptores de TR apresentaram alta mortalidade, associada ao tipo de doador, níveis de troponina, uso precoce de vasopressores e necessidade de VM. Os outros escores tradicionais de gravidade investigados não puderam predizer mortalidade.

Riesgo de complicaciones virales postrasplante en candidatos a trasplante renal con donante vivo / Risk of viral post-transplant complications in living donor kidney transplant candidates

Introducción: El trasplante renal con donante vivo se promueve en Cuba y en el resto del mundo. La definición del riesgo de complicaciones postrasplante por citomegalovirus (CMV) y virus de Epstein Barr (EBV) es parte de las pruebas de compatibilidad pretrasplante. Objetivo: Determinar el riesgo de complicaciones postrasplante con estos virus en pacientes cubanos candidatos a trasplante renal con donante vivo. Método: Se determinaron anticuerpos IgG anti-CMV e IgG anti-EBV por ensayo de inmunoabsorción ligado a enzima en 301 muestras de candidatos a TRDV y 390 de posibles donantes recibidas, entre julio de 2013 y julio de 2019, en el laboratorio de Histocompatibilidad del Instituto de Hematología e Inmunología. Resultados: En los candidatos a trasplante renal con donante vivo la seroprevalencia del EBV fue mayor que la del CMV y ambas aumentaron con la edad. El 100 % de los pacientes de grupo sanguíneo AB tuvieron EBV y CMV. No existió dependencia entre los anticuerpos anti-EBV y anti-CMV con los anticuerpos anti-HLA, la edad, sexo, color de la piel, grupo sanguíneo, hepatitis B y C, tipo de diálisis, trasplantes y transfusiones previas. El 7,3 % de los pacientes presentaron alto riesgo de complicaciones postrasplante. Conclusiones: La seroprevalencia de CMV y EBV en los candidatos a trasplante renal con donante vivo cubanos es alta, por lo que pocos tienen riesgo alto de complicaciones postrasplantes debido a estos virus(AU)

Introduction: Living donor kidney transplant is promoted in our country and the rest of the world. The definition of Cytomegalovirus (CMV) and Epstein Barr virus (EBV) post-transplant complications risk is part of pretransplant compatibility tests. Objective: To assess post-transplant complication risk with these viruses in Cuban candidates to living donor kidney transplant. Methods: Detection of IgG anti-CMV and IgG anti-EBV antibodies by enzyme-linked immunoabsorbent assay was performed on 301 receptors and 390 living donors' serum examples received, from July 2013 to July 2019, at the Histocompatibility department of the Institute of Hematology and Immunology. Results: In candidates to living donor kidney transplant, EBV seroprevalence was greater than CMV's and increased with age. The 100% of AB blood group had CMV and EBV. There was no association between IgG anti-CMV and IgG anti-EBV antibodies and anti-HLA antibodies, age, gender, skin color, blood group, hepatitis B and C, dialysis type, previous transplants, and transfusions. The 7.3% of patients were labeled as post-transplant complications high risk. Conclusions: The seroprevalence of CMV and EBV in living donor kidney transplant Cuban candidates is high, that´s why patients with high risk for post-transplant complications due to these viruses are a few(AU)

Rechazo crónico mediado por anticuerpos

Contexto el rechazo crónico mediado por anticuerpos (cABMR, chronic antibody-mediated rejection) se considera una de las principales causas de disfunción crónica del injerto. Objetivo profundizar en la comprensión de los mecanismos que la ocasionan para diseñar tratamientos efectivos, dado que es muy poco lo que se ha avanzado en el tratamiento de esta patología. Metodología en esta revisión narrativa de la literatura, presentamos los factores de riesgo relacionados con la disfunción crónica del injerto, haciendo énfasis en la fisiopatología, el diagnóstico y el tratamiento del cABMR. Resultados el factor de riesgo más relevante para el desarrollo de disfunción crónica del injerto es el desarrollo de anticuerpos donante específicos (DSA) y ABMR. Para el diagnóstico de cABMR activo, se requieren los criterios de Banff 2017 (los tres deben estar presentes: Evidencia histológica de lesión tisular crónica, evidencia de inflamación actual en el endotelio vascular ocasionada por anticuerpos y evidencia serológica de DSA. El cABMR no tiene un tratamiento efectivo. Conclusiones dado que cABMR no tiene un tratamiento efectivo, es importante disminuir la exposición a los factores de riesgo y hacer un diagnóstico y un tratamiento oportuno de los eventos agudos de lesión renal que contribuyen a la progresión de disfunción crónica del injerto.

Context Chronic antibody-mediated rejection (cABMR) is considered one of the main causes of chronic graft. Objective To review the mechanisms that cause cABMR to design effective treatments, since it is very little what has been advanced in it treatment of this pathology. Methodology In this narrative review of the literature, we present the risk factors related to the chronic dysfunction of the injection, emphasizing the pathophysiology the diagnosis and treatment of cABMR. Results The most relevant risk factor for the development of chronic graft dysfunction is the development of specific donor antibodies (DSA) and ABMR. For the diagnosis of active cABMR, the criteria of Banff 2017 are required (three must be present: histological evidence of chronic tissue injury, evidence of current inflammation in the vascular endothelium caused by antibodies and serological evidence of DSA. The cABMR does not have an effective treatment. Conclusions Since cABMR does not have an effective treatment, it is important reduce exposure to risk factors and carry out a diagnosis and treatment of the acute events of kidney injury that contribute to the progression of chronic injection dysfunction.

Embolización transcatéter del injerto renal en pacientes con síndrome de intolerancia: reporte de tres casos en un grupo de trasplantes

Introducción el síndrome de intolerancia es un proceso inflamatorio que ocurre hasta en un tercio de los pacientes con pérdida del injerto. Cuando no se obtiene una mejoría de los síntomas con el manejo médico, se indica la realización de nefrectomía del riñón trasplantado, sin embargo, este es un procedimiento invasivo que puede estar asociado a mayor morbilidad y mortalidad. Dada la fragilidad de estos pacientes, se plantea la embolización transcatéter del injerto como una alternativa válida y menos invasiva para el tratamiento de este síndrome. Objetivo describir el uso de la embolización transcatéter como tratamiento al síndrome de intolerancia del injerto. Presentación del caso se reportan tres casos clínicos de pacientes con sintomatología de entre 15 y 20 días de evolución, consistentes en dolor y tumefacción sobre riñón trasplantado y otros signos y síntomas reportados fueron fiebre, hiporexia, pérdida de peso y hematuria macroscópica. Se describe la evolución de los síntomas que en ninguno de los casos expuestos tuvieron mejoría con el ajuste inmunosupresor, descartando en todos los casos etiología infecciosa y estableciéndose así la sospecha síndrome de intolerancia del injerto. Los pacientes fueron manejados con embolización transcatéter de la arteria del riñón trasplantado y el éxito del tratamiento se definió por la resolución de los síntomas. Discusión y conclusión entre las primeras 24-48 horas posprocedimiento, los pacientes presentaron una evolución satisfactoria y, finalmente, egreso. La embolización transcatéter del injerto es una alternativa segura a la nefrectomía del trasplante y que es menos invasiva para el tratamiento del síndrome de intolerancia del injerto.

Background The renal graft intolerance syndrome is an inflammatory process that occurs in one third of the kidney transplant patients with graft loss. If medical treatment for intolerance graft syndrome is not effective, there is an indication of graft nephrectomy. However, graft nephrectomy has higher morbidity and mortality compared to non-invasive techniques. Due to a high fragility in kidney transplant patients, the renal arterial embolization has become a useful minimally invasive therapeutic option for intolerance graft syndrome. Objective We aim to describe the use of renal arterial embolization for renal graft intolerance syndrome. Case presentation We report three clinical cases who were admitted to the emergency department for a history of twenty days of graft pain and swelling. These patients had fever, hyporexia, weight loss and macroscopic hematuria. None of the cases had clinical improvement with immunosuppression adjustment and a diagnosis of renal graft intolerance syndrome was made dismissing infection. Patients were treated with renal arterial embolization and its procedure success were determined as the symptom's resolution. Discussion and conclusion After 24- and 48-hours post-embolization, patients were successfully recovered and discharged in the hospital. Renal graft arterial embolization is a safe and non-invasive alternative to graft nephrectomy to treat renal intolerance syndrome.

Caracterización inmunogenética de donantes cadavéricos cubanos en el año 2019 / Immunogenetic characterization of Cuban cadaveric donors in 2019

Introducción: El trasplante es la opción terapéutica más favorable para las personas con insuficiencia renal crónica. El donante puede ser cadavérico o donante vivo, emparentado o no. Los resultados del trasplante están en relación con varios factores inmunológicos y no inmunológicos. Objetivo: Caracterizar inmunogenéticamente a los donantes cadavéricos cubanos para trasplante renal. Métodos: Se realizó un estudio transversal y descriptivo de los donantes cadavéricos durante el año 2019. Se analizó la región de procedencia, sexo, color de la piel y rangos de edades de los donantes, así como, grupo sanguíneos ABO y Rhesus Rh; serología para VIH, Virus de hepatitis B(VHB) y Virus de hepatitis C (VHC); y hábitos tóxicos. Resultados: Se estudió un total de 95 donantes cadavéricos, 62 provenientes del occidente y 33 del centro del país. El 63,2 por ciento fueron masculinos y 36,8 por ciento femenino. El grupo de edad de mayor frecuencia fue 40 - 60 años y la edad media de 49,45 años. El 58,95 por ciento de los pacientes fueron de grupo sanguíneo O; 30,53 por ciento grupo A y los grupos B y AB tuvieron 5,26 por ciento de prevalencia; y solo 8 fueron Rh negativos. Todos tuvieron serología para VIH, VHB y VHC negativas. Las enfermedades asociadas más frecuentes fueron la hipertensión arterial y la diabetes mellitus. Conclusiones: Los donantes cadavéricos durante el año 2019 mostraron características similares a las reportadas por otros estudios. El aumento de las edades de los donantes incide en la aparición de enfermedades asociadas y esto pudiera repercutir en el resultado del trasplante(AU)

Introduction: Transplantation is the most favorable therapeutic option for people with chronic renal failure. The donor can be a cadaveric or living donor, related or not. Transplant outcomes are related to various immunological and non-immunological factors. Objective: To characterize Cuban cadaveric donors for renal transplantation Materials and methods: A cross-sectional and descriptive study of cadaveric donors was carried out during the year 2019. The region of origin, sex, skin color and age ranges of the donors were analyzed, as well as ABO and Rhesus Rh blood groups; serology for HIV, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV), and toxic habits. Results: A total of 95 cadaveric donors were studied, 62 from the West and 33 from the Center of the country. 63.2 percent were male and 36.8 percent female due to the most frequent age group being 40-60 years and the mean age of 49.45 years. 58.95 percent of the patients were of blood group O, 30.53 percent group A and groups B and AB had 5.26 percent prevalence; and only 8 were Rh negative. All had negative serology for HIV, HBV and HCV. The most frequent associated diseases were arterial hypertension and diabetes mellitus. Conclusions: The cadaveric donors during the year 2019 showed characteristics similar to those reported by other studies. The increase in the age of the donors affects the appearance of associated diseases and this could affect the result of the transplant(AU)