Use of Machine Perfusion to Increase the Number of Expanded Criteria Deceased Donor Kidney Transplants: A Pharmacoeconomic Analysis.

Background: The discard of expanded criteria donor (ECD) kidneys is unacceptably high, considering the growing demand for transplantation. Using machine perfusion may reduce the discard rate, increase the number of transplants, and reduce mortality on the waiting list. Methods: We developed a 5-y Markov model to simulate incorporating the pulsatile perfusion machine into the current government-funded healthcare system. The model compared the universal use of static cold storage for all kidneys with the selective use of machine perfusion for ECD kidneys. Real-life data were used to compose the cohort characteristics in this model. This pharmacoeconomic analysis aimed to determine the cost-effectiveness and budgetary impact of using machine perfusion to preserve ECD kidneys. Results: Compared with the universal use of static cold storage, the use of machine perfusion for ECD kidneys was associated with an increase in the number of kidney transplants (n = 1123), a decrease in the number of patients on the waiting list (n = 815), and decrease in mortality (n = 120), with a cost difference of US dollar 4 486 009 in the period. The budget impact analysis revealed an additional cost of US dollar 4 453 749 >5 y. The budget impact analysis demonstrated a progressive reduction in costs, becoming cost-saving during the last year of the analysis. Conclusions: This stochastic model showed that incorporating machine perfusion for ECD kidneys is most often a dominant or cost-effective technology associated with an increase in the number of transplants and a reduction in the number of patients on the waiting list, reducing mortality on the waiting list.

Radiological presentation of active pulmonary tuberculosis in kidney transplant recipients: a retrospective study of four cases and a review of the literature.

Although kidney transplantation is the best therapeutic option for patients with chronic kidney disease, the immunosuppression required greatly increases susceptibility to infections that are responsible for high post-transplant mortality. Pulmonary tuberculosis (TB) represents a major cause of such infections, and its early diagnosis is therefore quite important. In view of that, we researched the manifestations of active pulmonary TB in kidney transplant recipients, through chest X-ray and computed tomography (CT), as well as determining the number of cases of active pulmonary TB occurring over a 3.5-year period at our institution. We identified four cases of active pulmonary TB in kidney transplant recipients. The CT scans provided information complementary to the chest X-ray findings in all four of those cases. We compared our CT findings with those reported in the literature. We analyzed our experience in conjunction with an extensive review of the literature that was nevertheless limited because few studies have been carried out in lowand middle-income countries, where the incidence of TB is higher.

Apesar de o transplante renal ser a melhor opção terapêutica para pacientes com doença renal crônica, a imunodepressão decorrente desse tratamento eleva muito a suscetibilidade desses pacientes a infecções, responsáveis por altas taxas de mortalidade pós-operatórias. A tuberculose (TB) pulmonar é uma significativa causa dessas infecções, sendo muito importante o seu diagnóstico precoce. Assim, nós pesquisamos as manifestações da TB pulmonar ativa nessa população de transplantados renais por meio de radiografias simples e tomografia computadorizada (TC) do tórax, também para estabelecer o número de casos de TB pulmonar ativa em nossa instituição após levantamento de 3,5 anos. Encontramos quatro casos de TB pulmonar ativa em pacientes transplantados renais. A TC forneceu informações adicionais em relação às radiografias de tórax em 100% dos casos analisados. Comparamos os nossos achados de TC com os relatados na literatura. Somamos a experiência obtida com extensa revisão da literatura, ainda limitada nessa questão, com poucos estudos realizados em países em desenvolvimento onde a incidência de TB é maior.

Application of natural language processing to predict final recommendation of Brazilian health technology assessment reports.

INTRODUCTION: Health technology assessment (HTA) plays a vital role in healthcare decision-making globally, necessitating the identification of key factors impacting evaluation outcomes due to the significant workload faced by HTA agencies. OBJECTIVES: The aim of this study was to predict the approval status of evaluations conducted by the Brazilian Committee for Health Technology Incorporation (CONITEC) using natural language processing (NLP). METHODS: Data encompassing CONITEC's official report summaries from 2012 to 2022. Textual data was tokenized for NLP analysis. Least Absolute Shrinkage and Selection Operator, logistic regression, support vector machine, random forest, neural network, and extreme gradient boosting (XGBoost), were evaluated for accuracy, area under the receiver operating characteristic curve (ROC AUC) score, precision, and recall. Cluster analysis using the k-modes algorithm categorized entries into two clusters (approved, rejected). RESULTS: The neural network model exhibited the highest accuracy metrics (precision at 0.815, accuracy at 0.769, ROC AUC at 0.871, and recall at 0.746), followed by XGBoost model. The lexical analysis uncovered linguistic markers, like references to international HTA agencies' experiences and government as demandant, potentially influencing CONITEC's decisions. Cluster and XGBoost analyses emphasized that approved evaluations mainly concerned drug assessments, often government-initiated, while non-approved ones frequently evaluated drugs, with the industry as the requester. CONCLUSIONS: NLP model can predict health technology incorporation outcomes, opening avenues for future research using HTA reports from other agencies. This model has the potential to enhance HTA system efficiency by offering initial insights and decision-making criteria, thereby benefiting healthcare experts.

Body fat predicts urinary tract infection in kidney transplant recipients: a prospective cohort study.

BACKGROUND: The association between obesity and infectious diseases is increasingly reported in the literature. There are scarce studies on the association between obesity and urinary tract infection after kidney transplantation (KTx). These studies defined obesity based on body mass index, and their results were conflicting. The present study aimed to evaluate this association using bioelectrical impedance analysis for body composition evaluation, and obesity definition. METHODS: A single-center cohort study was conducted. Demographic, clinical, anthropometric, and laboratory data were collected at KTx admission, and bioelectrical impedance analysis was performed to measure the visceral fat area, waist circumference, and total fat mass. The occurrence of urinary tract infection (symptomatic bacteriuria and/or histological evidence of pyelonephritis) was evaluated within three months after KTx. RESULTS: Seventy-seven patients were included in the cohort, and 67 were included in the final analysis. Urinary tract infection was diagnosed in 23.9% of the transplanted patients. Waist circumference (HR: 1.053; 95% CI 1.005-1.104; p = 0.032), visceral fat area (HR: 1.015; 95% CI 1.003-1.027; p = 0.014), and total fat mass (HR: 1.075; 95% CI 1.008-1.146; p = 0.028) were associated with urinary tract infection occurrence after KTx, using Cox regression models. Patients with high waist circumference (above 102 cm for men and above 88 cm for women) had a 4.7 times higher risk of a urinary tract infection than those with normal waist circumference (HR: 4.726; 95% CI 1.267-17.630; p = 0.021). Kaplan-Meier curves showed that patients with high waist circumference, high visceral fat area, and high total fat mass had more urinary tract infections (Log-rank test p = 0.014, p = 0.020, and p = 0.018, respectively). Body mass index was not able to predict urinary tract infection in the study sample. CONCLUSIONS: Waist circumference, visceral fat area, and total fat mass, assessed by bioelectrical impedance analysis, were predictors of urinary tract infection risk within the first three months after KTx.

Safety of cinacalcet in children and adolescents with chronic kidney disease-mineral bone disorder: systematic review and proportional meta-analysis of case series.

BACKGROUND: Mineral and bone disease in children with chronic kidney disease can cause abnormalities in calcium, phosphorus, parathyroid hormone, and vitamin D and when left untreated can result in impaired growth, bone deformities, fractures, and vascular calcification. Cinacalcet is a calcimimetic widely used as a therapy to reduce parathyroid hormone levels in the adult population, with hypocalcemia among its side effects. The analysis of safety in the pediatric population is questioned due to the scarcity of randomized clinical trials in this group. OBJECTIVE: To assess the onset of symptomatic hypocalcemia or other adverse events (serious or non-serious) with the use of cinacalcet in children and adolescents with mineral and bone disorder in chronic kidney disease. DATA SOURCES AND STUDY ELIGIBILITY CRITERIA: The bibliographic search identified 2699 references from 1927 to August/2023 (57 LILACS, 44 Web of Science, 686 PubMed, 131 Cochrane, 1246 Scopus, 535 Embase). Four references were added from the bibliography of articles found and 12 references from the gray literature (Clinical Trials). Of the 77 studies analyzed in full, 68 were excluded because they did not meet the following criteria: population, types of studies, medication, publication types and 1 article that did not present results (gray literature). PARTICIPANTS AND INTERVENTIONS: There were 149 patients aged 0-18 years old with Chronic Kidney Disease and mineral bone disorder who received cinacalcet. STUDY APPRAISAL AND SYNTHESIS METHODS: Nine eligible studies were examined for study type, size, intervention, and reported outcomes. RESULTS: There was an incidence of 0.2% of fatal adverse events and 16% of serious adverse events (p < 0.01 and I2 = 69%), in addition to 10.7% of hypocalcemia, totaling 45.7% of total adverse events. LIMITATIONS: There was a bias in demographic information and clinical characteristics of patients in about 50% of the studies and the majority of the studies were case series. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: If used in the pediatric population, the calcimimetic cinacalcet should be carefully monitored for serum calcium levels and attention to possible adverse events, especially in children under 50 months. SYSTEMATIC REVIEW REGISTRATION NUMBER (PROSPERO REGISTER): CRD42019132809.

Radiological presentation of active pulmonary tuberculosis in kidney transplant recipients: a retrospective study of four cases and a review of the literature / Apresentação radiológica da tuberculose pulmonar ativa em transplantados renais: um estudo retrospectivo de quatro casos e revisão da literatura

Abstract Although kidney transplantation is the best therapeutic option for patients with chronic kidney disease, the immunosuppression required greatly increases susceptibility to infections that are responsible for high post-transplant mortality. Pulmonary tuberculosis (TB) represents a major cause of such infections, and its early diagnosis is therefore quite important. In view of that, we researched the manifestations of active pulmonary TB in kidney transplant recipients, through chest X-ray and computed tomography (CT), as well as determining the number of cases of active pulmonary TB occurring over a 3.5-year period at our institution. We identified four cases of active pulmonary TB in kidney transplant recipients. The CT scans provided information complementary to the chest X-ray findings in all four of those cases. We compared our CT findings with those reported in the literature. We analyzed our experience in conjunction with an extensive review of the literature that was nevertheless limited because few studies have been carried out in lowand middle-income countries, where the incidence of TB is higher.

Resumo Apesar de o transplante renal ser a melhor opção terapêutica para pacientes com doença renal crônica, a imunodepressão decorrente desse tratamento eleva muito a suscetibilidade desses pacientes a infecções, responsáveis por altas taxas de mortalidade pós-operatórias. A tuberculose (TB) pulmonar é uma significativa causa dessas infecções, sendo muito importante o seu diagnóstico precoce. Assim, nós pesquisamos as manifestações da TB pulmonar ativa nessa população de transplantados renais por meio de radiografias simples e tomografia computadorizada (TC) do tórax, também para estabelecer o número de casos de TB pulmonar ativa em nossa instituição após levantamento de 3,5 anos. Encontramos quatro casos de TB pulmonar ativa em pacientes transplantados renais. A TC forneceu informações adicionais em relação às radiografias de tórax em 100% dos casos analisados. Comparamos os nossos achados de TC com os relatados na literatura. Somamos a experiência obtida com extensa revisão da literatura, ainda limitada nessa questão, com poucos estudos realizados em países em desenvolvimento onde a incidência de TB é maior.

Medicina e espiritualidade: o perfil de estudantes e médicos de uma escola médica brasileira / Medicine and spirituality: the profile of students and physicians at a Brazilian medical school

Resumo Introdução: Pesquisas científicas indicam que a espiritualidade desempenha um papel importante na vida da maioria dos pacientes. Além disso, atividades e crenças religiosas podem, de acordo com algumas pesquisa, estar relacionadas à melhor saúde e qualidade de vida1. Objetivo: Este estudo teve como objetivos avaliar o nível de espiritualidade de estudantes de Medicina e de médicos já formados, e analisar o ensino da interface "medicina e espiritualidade" na escola médica. Método: Realizamos um estudo transversal descritivo por meio da aplicação de questionários a estudantes de Medicina e médicos de uma escola médica pública brasileira. Resultado: Avaliaram-se 234 participantes. A maioria acredita em uma força superior. A espiritualidade foi maior entre médicos já formados e entre pessoas do sexo feminino. A maioria acredita que a formação universitária não prepara o médico para abordar o tema com os pacientes. Apesar dessa limitação, a maioria já abordou a espiritualidade com seus pacientes. Conclusão: Médicos e estudantes de Medicina consideram importante contemplar, de maneira ecumênica e respeitosa, aspectos espirituais dos pacientes. Apesar disso, consideram que não receberam preparo suficiente na escola médica para essa abordagem.

Abstract Introduction: Scientific research indicates that spirituality plays an important role in the daily life of most patients. Moreover, there are studies indicating that religious activities and beliefs may be related to better health and quality of life1. Objective: to evaluate the level of spirituality of medical students and graduated physicians, in addition to analyzing the teaching of the "Medicine and Spirituality" interface in medical school. Methodology: A descriptive cross-sectional study was carried out by applying questionnaires to medical students and doctors at a Brazilian public medical school. Results: a total of 234 participants were evaluated. Most believe in a higher power. Spirituality was higher among doctors who had already graduated and among females. Most believe that university education does not prepare doctors to address the topic with the patients. Despite this limitation, most have already discussed spirituality with their patients. Conclusion: Doctors and medical students consider it important to contemplate spiritual aspects of patients using an ecumenical and respectful approach. Nevertheless, they consider they were not sufficiently prepared in medical school for this approach.

Genetic and phenotypic profile of Fabry disease in the population of Vale do Paraiba and Eastern São Paulo / Perfil genético e fenotípico da doença de Fabry na população do Vale do Paraíba e Zona Leste de São Paulo

ABSTRACT Introduction: Fabry disease (FD) is an inborn error of metabolism characterized by α-galactosidase A deficiency. The primary objective was to evaluate the genetic and phenotypic profile of Fabry disease in hemodialysis. Methods: Observational cohort study to determine the incidence of genetic variations and phenotypic changes for FD in hemodialysis patients in the Paraiba Valley and Eastern São Paulo. Genetic testing for the GLA gene was performed for men and women over 12 years of age at the hemodialysis clinics between January 2016 and December 2019 as a screening protocol. Results: The cases came from screening exams of the index case among patients with chronic kidney disease, resulting in 17 families and totaling 82 patients under study. The classification of the most prevalent variant was that of uncertain significance (54%), followed by the pathogenic variant (46%). Five patients in two families were described with two types of variants not previously described in the literature, with pathogenic behavior. Comparing the types of variants, the presence of a pathogenic variant was associated with higher levels of lysoGB3, lower values for alpha-GAL activity and higher frequency of symptoms related to FD. Conclusion: We characterized an extensive population of patients with FD variants with rich genetic, clinical and biomarker details. We believe that this study can help to better characterize the Brazilian population with FD and the most frequent types of variants.

RESUMO Introdução: A doença de Fabry (DF) é um erro inato do metabolismo caracterizado pela deficiência da enzima α-galactosidase A. O objetivo primário foi avaliar o perfil genético e fenotípico da doença de Fabry em hemodiálise. Métodos: Estudo de coorte observacional para determinar a incidência de variações genéticas e alterações fenotípicas para DF em pacientes em hemodiálise no Vale do Paraíba e Zona Leste de São Paulo. O teste genético para o gene GLA foi realizado para homens e mulheres em todos os pacientes das clínicas de hemodiálise maiores de 12 anos entre janeiro de 2016 a dezembro de 2019 como protocolo de rastreio. Resultados: Os casos foram provenientes de exames de triagem do caso índice entre pacientes portadores de doença renal crônica, resultando em 17 famílias e totalizando 82 pacientes em estudo. A classificação da variante mais prevalente foi a de significado incerto (54%), seguida da variante patogênica (46%). Foram descritos 5 pacientes em duas famílias com dois tipos de variantes ainda não previamente descritos na literatura com comportamento patogênico. Na comparação entre os tipos de variantes, a presença de variante patogênica foi associada a maiores níveis de lysoGB3, menores valores da atividade da alfa-GAL e maior frequência de sintomas relativos à DF. Conclusão: Caracterizamos uma extensa população de pacientes com variantes para DF com riqueza de detalhes de genética, clínica e de biomarcadores. Acreditamos que este estudo possa auxiliar na melhor caracterização da população brasileira com DF e nos tipos mais frequentes de variantes.

A comprehensive model for assessing and classifying patients with thrombotic microangiopathy: the TMA-INSIGHT score.

BACKGROUND: Thrombotic Microangiopathy (TMA) is a syndrome characterized by the presence of anemia, thrombocytopenia and organ damage and has multiple etiologies. The primary aim is to develop an algorithm to classify TMA (TMA-INSIGHT score). METHODS: This was a single-center retrospective cohort study including hospitalized patients with TMA at a single center. We included all consecutive patients diagnosed with TMA between 2012 and 2021. TMA was defined based on the presence of anemia (hemoglobin level < 10 g/dL) and thrombocytopenia (platelet count < 150,000/µL), signs of hemolysis, and organ damage. We classified patients in eight categories: infections; Malignant Hypertension; Transplant; Malignancy; Pregnancy; Thrombotic Thrombocytopenic Purpura (TTP); Shiga toxin-mediated hemolytic uremic syndrome (STEC-SHU) and Complement Mediated TMA (aHUS). We fitted a model to classify patients using clinical characteristics, biochemical exams, and mean arterial pressure at presentation. RESULTS: We retrospectively retrieved TMA phenotypes using automatic strategies in electronic health records in almost 10 years (n = 2407). Secondary TMA was found in 97.5% of the patients. Primary TMA was found in 2.47% of the patients (TTP and aHUS). The best model was LightGBM with accuracy of 0.979, and multiclass ROC-AUC of 0.966. The predictions had higher accuracy in most TMA classes, although the confidence was lower in aHUS and STEC-HUS cases. CONCLUSION: Secondary conditions were the most common etiologies of TMA. We retrieved comorbidities, associated conditions, and mean arterial pressure to fit a model to predict TMA and define TMA phenotypic characteristics. This is the first multiclass model to predict TMA including primary and secondary conditions.

Machine Learning Model to Predict Graft Rejection After Kidney Transplantation.

BACKGROUND: There are few predictive studies about early posttransplant outcomes taking into account baseline and posttransplant variables. The objective of this study was to create a predictive model for 30-day graft rejection using machine learning techniques. METHODS: Retrospective study with 1255 patients undergoing transplant from living and deceased donors at a tertiary health service in Brazil. Recipient, donor, transplantation, and postoperative period data were collected from physical and electronic records. We split the data into derivation (training) and validation (test) datasets. Five supervised machine learning algorithms were developed with this subset of variables in the training set: Simple Logistic Regression, Lasso, Multilayer Perceptron, XGBoost, and Light GBM. RESULTS: There were 147 (12.48%) cases of graft rejection within 30 days of transplantation. The best model was XGBoost (accuracy, 0.839; receiver operating characteristic area under the curve, 0.715; precision, 0.900). The model showed that deceased donor transplantation, glomerulopathy as an underlying disease, and donor's use of vasoactive drugs had more than 20% importance as rejection risk factors. The variables with the greatest predictive values were thymoglobulin induction and delayed graft function. CONCLUSIONS: We fitted a machine learning model to predict 30-day graft rejection after kidney transplantation that reaches a higher accuracy and precision. Machine learning models could contribute to predicting kidney survival using nontraditional approaches.

Cost-effectiveness analysis of cinacalcet vs. paricalcitol in the treatment of hyperparathyroidism secondary to chronic kidney disease / Análise de custo-efetividade do cinacalcete vs. paricalcitol no tratamento do hiperparatireoidismo secundário à doença renal crônica

ABSTRACT Introduction For the reduction of PTH levels, two classes of drugs are available in the Brazilian market: non-selective and selective vitamin D receptor activators and calcimimetics. Among the mentioned drugs, the SUS provides oral calcitriol, paricalcitol and cinacalcet. Objectives: Develop cost-effectiveness (CE) and budgetary impact (BI) analysis of cinacalcet versus paricalcitol for patients on dialysis with SHPT, from the perspective of SUS. Methodology: A decision tree model was constructed for CE analysis, which considered the outcome of avoided parathyroidectomy and a time horizon of 1 year. As for the BI analysis, two scenarios were considered, one of which was measured demand and other epidemiological, based on data from the Brazilian Society of Nephrology (BSN). Results: The CE analysis showed that the use of cinacalcet results in one-off savings of R$1,394.64 per year and an incremental effectiveness of 0.08, in relation to avoided parathyroidectomy. The incremental CE ratio (ICER) was - R$ 17,653.67 per avoided parathyroidectomy for cinacalcet, as it was more effective and cheaper compared to paricalcitol. As for the BI analysis, it was estimated that the incremental BI with the expansion of the use of cinacalcet in the SUS will be between - R$ 1,640,864.62 and R$ 166,368.50 in the first year, considering the main and the epidemiological scenarios. At the end of 5 years after the expansion of use, an BI was estimated between - R$ 10,740,743.86 and - R$ 1,191,339.37; considering the same scenarios. Conclusion: Cinacalcet was dominant to avoid parathyroidectomies, being cost-effective.

RESUMO Introdução: Para a redução dos níveis do paratormônio (PTH) estão disponíveis no mercado brasileiro duas classes de medicamentos: ativadores do receptor da vitamina D (não seletivos e seletivos) e calcimiméticos. Dentre os medicamentos supracitados, o SUS disponibiliza calcitriol oral, paricalcitol e cinacalcete. Objetivos: Desenvolver análise de custo-efetividade (CE) e de impacto orçamentário (IO) do cinacalcete versus paricalcitol para pacientes em diálise com HPTS, na perspectiva do SUS. Metodologia: Foi construído um modelo de árvore de decisão para a análise de CE, que considerou o desfecho paratireoidectomia evitada e um horizonte temporal de 1 ano. Quanto à análise de IO, foram considerados dois cenários, um de demanda aferida e outro de abordagem epidemiológica, baseado nos dados da Sociedade Brasileira de Nefrologia (SBN). Resultados: A análise de CE mostrou que o uso de cinacalcete resulta em economia de R$ 1.394,64 ao ano e efetividade incremental de 0,08, em relação a paratireoidectomia evitada. A razão de CE incremental (RCEI) foi de - R$ 17.653,67 por paratireoidectomia evitada para o cinacalcete, já que se mostrou mais efetivo e mais barato comparado ao paricalcitol. Estimou-se que o IO incremental com a ampliação do uso do cinacalcete no SUS estará entre - R$ 1.640.864,62 e R$ 166.368,50 no primeiro ano, considerando os cenários principal e epidemiológico baseado nos dados da SBN. Já ao final de 5 anos após a ampliação do uso, estimou-se um impacto incremental entre - R$ 10.740.743,86 e - R$ 1.191.339,37; considerando os mesmos cenários. Conclusão: Cinacalcete foi dominante para evitar paratireoidectomias, sendo custo-efetivo.

Exploring the COVID-19 Pandemic's Impact on the Health Technology Assessment Process of the National Commission for the Incorporation of Technologies Into the Brazilian Health System.

OBJECTIVES: This study aimed to evaluate the impact of the COVID-19 pandemic on Brazilian health technology assessment processes based on public reports from the National Committee for Health Technology Incorporation (CONITEC). METHODS: This descriptive study analyzed CONITEC's official reports on Brazil available on its website between 2018 and 2021 that aimed to propose recommendations for technologies to be incorporated into its public healthcare system. We used descriptive statistics covering the number of technologies and number of reports about drugs per year, objective, type of technology, demanding sector, and outcome before 2018 to 2019 and during the COVID-19 pandemic (2020-2021). Furthermore, we used logistic regression to explore any association between the final decision labeled as "incorporated" and the emergence of the COVID-19 pandemic. RESULTS: A total of 278 reports were analyzed. Approximately 85% (136 of 278), 79% (220 of 278), and 45% of the reports (125 of 278) were about drugs, for incorporation, and requested by the government, respectively. Moreover, 74 of 130 (57%) and 56 of 148 decisions (38%) were "incorporated" before and during the pandemic, respectively. No significant association was noted between incorporated decisions and the arrival of the COVID-19 pandemic for all technologies (odds ratio 1.43; 95% CI 0.84-2.46; P = .192) and for drugs (odds ratio 1.43; 95% confidence interval 0.81-2.53; P = .223) while adjusting for the type of technology and demandant. CONCLUSIONS: The COVID-19 pandemic has brought many challenges, but it does not seem to have had a significant impact on the health technology assessment approval decisions of CONITEC in Brazil.

Cost-effectiveness analysis of cinacalcet vs. paricalcitol in the treatment of hyperparathyroidism secondary to chronic kidney disease.

INTRODUCTION: For the reduction of PTH levels, two classes of drugs are available in the Brazilian market: non-selective and selective vitamin D receptor activators and calcimimetics. Among the mentioned drugs, the SUS provides oral calcitriol, paricalcitol and cinacalcet. OBJECTIVES: Develop cost-effectiveness (CE) and budgetary impact (BI) analysis of cinacalcet versus paricalcitol for patients on dialysis with SHPT, from the perspective of SUS. METHODOLOGY: A decision tree model was constructed for CE analysis, which considered the outcome of avoided parathyroidectomy and a time horizon of 1 year. As for the BI analysis, two scenarios were considered, one of which was measured demand and other epidemiological, based on data from the Brazilian Society of Nephrology (BSN). RESULTS: The CE analysis showed that the use of cinacalcet results in one-off savings of R$1,394.64 per year and an incremental effectiveness of 0.08, in relation to avoided parathyroidectomy. The incremental CE ratio (ICER) was - R$ 17,653.67 per avoided parathyroidectomy for cinacalcet, as it was more effective and cheaper compared to paricalcitol. As for the BI analysis, it was estimated that the incremental BI with the expansion of the use of cinacalcet in the SUS will be between - R$ 1,640,864.62 and R$ 166,368.50 in the first year, considering the main and the epidemiological scenarios. At the end of 5 years after the expansion of use, an BI was estimated between - R$ 10,740,743.86 and - R$ 1,191,339.37; considering the same scenarios. CONCLUSION: Cinacalcet was dominant to avoid parathyroidectomies, being cost-effective.

Development and validation of a simple machine learning tool to predict mortality in leptospirosis.

Predicting risk factors for death in leptospirosis is challenging, and identifying high-risk patients is crucial as it might expedite the start of life-saving supportive care. Admission data of 295 leptospirosis patients were enrolled, and a machine-learning approach was used to fit models in a derivation cohort. The comparison of accuracy metrics was performed with two previous models-SPIRO score and quick SOFA score. A Lasso regression analysis was the selected model, demonstrating the best accuracy to predict mortality in leptospirosis [area under the curve (AUC-ROC) = 0.776]. A score-based prediction was carried out with the coefficients of this model and named LeptoScore. Then, to simplify the predictive tool, a new score was built by attributing points to the predictors with importance values higher than 1. The simplified score, named QuickLepto, has five variables (age > 40 years; lethargy; pulmonary symptom; mean arterial pressure < 80 mmHg and hematocrit < 30%) and good predictive accuracy (AUC-ROC = 0.788). LeptoScore and QuickLepto had better accuracy to predict mortality in patients with leptospirosis when compared to SPIRO score (AUC-ROC = 0.500) and quick SOFA score (AUC-ROC = 0.782). The main result is a new scoring system, the QuickLepto, that is a simple and useful tool to predict death in leptospirosis patients at hospital admission.

Cost-effectiveness analysis of intravenous paricalcitol vs. oral calcitriol in the treatment of hyperparathyroidism secondary to chronic kidney disease / Análise de custo-efetividade do paricalcitol intravenoso vs. calcitriol oral no tratamento do hiperparatireoidismo secundário à doença renal crônica

Abstract Introduction: Hyperparathyroidism (SHPT) secondary to chronic kidney disease (CKD) is characterized by high levels of parathyroid hormone (PTH), hyperplasia of the parathyroid glands and cardiovascular disease. Selective and non-selective and selective vitamin D-receptor activators, calcimimetics, are available in the Brazilian market to reduce PTH levels. Objectives: To develop a cost-effectiveness (C/E) and budgetary impact (BI) analysis of intravenous paricalcitol vs. oral calcitriol for patients on dialysis with SHPT, from the perspective of the Brazilian Public Health Care System (SUS). Methodology: We built a decision-tree model to analyze C/E, which considered the outcome of avoided death and a time horizon of 1 year. As for the BI analysis, two scenarios were considered, one of demand and one of epidemiological approach, based on data from the Brazilian Society of Nephrology. Results: The analysis showed that the C/E ratio was R$ 1,213.68 per year, and an incremental effectiveness of 0.032, referring to avoided death. The incremental C/E ratio was R$37,927.50 per death averted by paricalcitol. It was estimated that the incremental BI with the expansion of paricalcitol use will be between R$1,600,202.28 and R$4,128,565.65 in the first year, considering the main and epidemiological scenarios. At the end of 5 years after the expansion of its use, an incremental BI was estimated between R$ 48,596,855.50 and R$ 62,90,555.73. Conclusion: Intravenous paricalcitol has superior efficacy and similar safety to oral calcitriol, reducing the overall mortality of dialysis patients, although it implies a higher cost.

Resumo Introdução: O hiperparatireoidismo secundário (HPTS) à doença crônica renal (DRC) é caracterizado por elevados níveis de paratormônio (PTH), hiperplasia das glândulas paratireoides e doença cardiovascular. Para a redução dos níveis do PTH, estão disponíveis no mercado brasileiro os ativadores não seletivos e seletivos do receptor da vitamina D e os calcimiméticos. Objetivos: Desenvolver análise de custo-efetividade (C/E) e de impacto orçamentário (IO) do paricalcitol intravenoso vs. calcitriol oral para pacientes em diálise com HPTS, na perspectiva do Sistema Único de Saúde. Metodologia: Foi construído um modelo de árvore de decisão para a análise de C/E, que considerou o desfecho morte evitada e um horizonte temporal de 1 ano. Quanto à análise de IO, foram considerados dois cenários, sendo um de demanda aferida e um de abordagem epidemiológica, baseado nos dados da Sociedade Brasileira de Nefrologia. Resultados: A análise mostrou que a relação de C/E foi de R$ 1.213,68 ao ano, e uma efetividade incremental de 0,032, referente à morte evitada. A razão de C/E incremental foi de R$ 37.927,50 por morte evitada para o paricalcitol. Estimou-se que o IO incremental com a ampliação do uso do paricalcitol estará entre R$ 1.600.202,28 e R$ 4.128.565,65 no primeiro ano, considerando os cenários principal e o epidemiológico. Já no fim de 5 anos após a ampliação do uso, estimou-se IO incremental entre R$ 48.596.855,50 e R$ 62.90.555,73. Conclusão: O paricalcitol intravenoso tem eficácia superior e segurança semelhante ao comparador calcitriol oral, diminuindo a mortalidade geral dos pacientes em diálise, embora implique maior custo.

Genetic and phenotypic profile of Fabry disease in the population of Vale do Paraiba and Eastern São Paulo.

INTRODUCTION: Fabry disease (FD) is an inborn error of metabolism characterized by α-galactosidase A deficiency. The primary objective was to evaluate the genetic and phenotypic profile of Fabry disease in hemodialysis. METHODS: Observational cohort study to determine the incidence of genetic variations and phenotypic changes for FD in hemodialysis patients in the Paraiba Valley and Eastern São Paulo. Genetic testing for the GLA gene was performed for men and women over 12 years of age at the hemodialysis clinics between January 2016 and December 2019 as a screening protocol. RESULTS: The cases came from screening exams of the index case among patients with chronic kidney disease, resulting in 17 families and totaling 82 patients under study. The classification of the most prevalent variant was that of uncertain significance (54%), followed by the pathogenic variant (46%). Five patients in two families were described with two types of variants not previously described in the literature, with pathogenic behavior. Comparing the types of variants, the presence of a pathogenic variant was associated with higher levels of lysoGB3, lower values for alpha-GAL activity and higher frequency of symptoms related to FD. CONCLUSION: We characterized an extensive population of patients with FD variants with rich genetic, clinical and biomarker details. We believe that this study can help to better characterize the Brazilian population with FD and the most frequent types of variants.

Cost-effectiveness analysis of intravenous paricalcitol vs. oral calcitriol in the treatment of hyperparathyroidism secondary to chronic kidney disease.

INTRODUCTION: Hyperparathyroidism (SHPT) secondary to chronic kidney disease (CKD) is characterized by high levels of parathyroid hormone (PTH), hyperplasia of the parathyroid glands and cardiovascular disease. Selective and non-selective and selective vitamin D-receptor activators, calcimimetics, are available in the Brazilian market to reduce PTH levels. OBJECTIVES: To develop a cost-effectiveness (C/E) and budgetary impact (BI) analysis of intravenous paricalcitol vs. oral calcitriol for patients on dialysis with SHPT, from the perspective of the Brazilian Public Health Care System (SUS). METHODOLOGY: We built a decision-tree model to analyze C/E, which considered the outcome of avoided death and a time horizon of 1 year. As for the BI analysis, two scenarios were considered, one of demand and one of epidemiological approach, based on data from the Brazilian Society of Nephrology. RESULTS: The analysis showed that the C/E ratio was R$ 1,213.68 per year, and an incremental effectiveness of 0.032, referring to avoided death. The incremental C/E ratio was R$37,927.50 per death averted by paricalcitol. It was estimated that the incremental BI with the expansion of paricalcitol use will be between R$1,600,202.28 and R$4,128,565.65 in the first year, considering the main and epidemiological scenarios. At the end of 5 years after the expansion of its use, an incremental BI was estimated between R$ 48,596,855.50 and R$ 62,90,555.73. CONCLUSION: Intravenous paricalcitol has superior efficacy and similar safety to oral calcitriol, reducing the overall mortality of dialysis patients, although it implies a higher cost.

Renal function at 12 months of kidney transplantation comparing tacrolimus and mycophenolate with tacrolimus and mTORi in donors with different KDPI ranges. A multicenter cohort study using propensity scoring.

Introduction: The combination of tacrolimus/mTORi compared to tacrolimus/mycophenolate (MMF) was shown to be safe in the TRANSFORM trial. For donors with a high KDPI (Kidney Donor Profile Index), however, there are no data to support the effectiveness of this regimen. The main objective of this study was to explore the influence of the KDPI on 12-month renal function (eGFR) in patients receiving mTORi or MMF. Methods: Multicenter cohort study of four Brazilian services that use the tacrolimus with mTORi as a protocol. Data from 2008 to 2018 of the tacrolimus/mycophenolate (MMF) and tacrolimus/mTORi (mTORi) regimens in renal transplant recipients over 18 years old were collected. For better homogeneity, the propensity score was used. Afterward, the method used for group selection ("match") was the K-nearest neighbor (KNN) method. New analyses were performed on this new balanced sample, and two different subsamples were constituted based on the median KDPI. Results: The global analysis (n = 870) showed that the major determinant of worse kidney function was high KDPI. Afterward, the three strata were analyzed. In the first stratum (KDPI up to 50), 242 patients were evaluated, with 121 in each group. The eGFR was 64 ml/min/1.73 m2 in the mTORi group compared to 63 in the MMF group, p = 0.4, and when imputed eGFR was evaluated, 61 in the mTORi and 53 in the MMF, p = 0.065. In the second stratum (KDPI from 50 to 85), 282 patients were evaluated, with 141 in each group. eGFR was 46 ml/min/1.73 m2 in mTORi compared to 48 in MMF, p = 0.4, and when imputed eGFR was evaluated, 40 mTORi and 41 MMF, p = 0.8. In the last stratum (KDPI higher than 85) with n = 126 and 63 cases per group, eGFR was 36 ml/min/1.73 m2 in mTORi compared to 39 in MMF, p = 0.2, and when imputed eGFR was evaluated, 30 mTORi and 34 MMF, p = 0.2. Discussion: The regimen using mTOR inhibitor is an effective and safe regimen when compared to the standard regimen. In addition, the scheme seems to offer additional protection against infections and may be an important ally in cases of high risk for these pathologies.

Effects of Plasma-Lyte® and 0. 9% saline in renal function after deceased-donor kidney transplant: a randomized controlled trial

Abstract Background The influence of different crystalloid solutions infused during deceased-donor kidney transplant on the incidence of delayed graft function remains unclear. We investigated the influence of Plasma-Lyte® vs. 0.9% saline on the incidence of delayed graft function in deceased-donor kidney transplant recipients. Methods We conducted a single-blind randomized controlled trial of 104 patients aged 18 to 65 years who underwent deceased-donor kidney transplant under general anesthesia. Patients were randomly assigned to receive either Plasma-Lyte® (n = 52) or 0.9% saline (n = 52), at the same infusion volume, for intraoperative fluid replacement. The primary outcome was the occurrence of delayed graft function. Secondary outcomes included metabolic and electrolytic changes at the end of surgery. Results Two patients in the Plasma-Lyte® group and one in the 0.9% saline group died postoperatively and were not included for analysis. The incidence of delayed graft function in Plasma-Lyte® and 0.9% saline groups were 60.0% (95% Confidence Interval [95% CI 46.2-72.4]) and 74.5% (95% CI 61.1-84.4), respectively (p= 0.140). Mean (standard deviation) values of immediate postoperative pH and serum chloride levels in Plasma-Lyte® and 0.9% saline groups were 7.306 (0.071) and 7.273 (0.061) (p= 0.013), and 99.6 (4.2) mEq.L-1 and 103.3 (5.6) mEq.L-1, respectively (p< 0.001). All other postoperative metabolic and electrolyte variables were not statistically different at the immediate postoperative period (p> 0.05). Conclusion In deceased-donor kidney transplant recipients, the incidence of delayed graft function is not influenced by Plasma-Lyte® or 0.9% saline used for intraoperative fluid replacement.

Impact of the COVID-19 Pandemic on Solid Organ Transplant and Rejection Episodes in Brazil's Unified Healthcare System.

BACKGROUND: Brazil has the world's largest public organ transplant program, which was severely affected by the COVID-19 pandemic. The primary aim of the study was to evaluate differences in solid organ transplants and rejection episodes during the COVID-19 pandemic compared to the five years before the pandemic in the country. METHODS: A seven-year database was built by downloading data from the DATASUS server. The pandemic period was defined as March 2020 to December 2021. The pre-pandemic period was from January 2015 to March 2020. RESULTS: During the pandemic, the number of solid organ transplants decreased by 19.3% in 2020 and 22.6% in 2021 compared to 2019. We found a decrease for each evaluated organ, which was more pronounced for lung, pancreas, and kidney transplants. The seasonal plot of rejection data indicated a high rejection rate between 2018 and 2021. There was also an 18% (IRR 1.18 (95% CI 1.01 to 1.37), p = 0.04) increase in the rejection rate during the COVID-19 pandemic. CONCLUSIONS: The total number of organ transplants performed in 2021 represents a setback of six years. Transplant procedures were concentrated in the Southeast region of the country, and a higher proportion of rejections occurred during the pandemic. Together, these findings could have an impact on transplant procedures and outcomes in Brazil.