Kidney transplantation process in Brazil represented in business process modeling notation.

Kidney transplantation is considered to be the best treatment for people with chronic kidney failure, because it improves the patients' quality of life and increases their length of survival compared with patients undergoing dialysis. The kidney transplantation process in Brazil is defined through laws, decrees, ordinances, and resolutions, but there is no visual representation of this process. The aim of this study was to analyze official documents to construct a representation of the kidney transplantation process in Brazil with the use of business process modeling notation (BPMN). The methodology for this study was based on an exploratory observational study, document analysis, and construction of process diagrams with the use of BPMN. Two rounds of validations by specialists were conducted. The result includes the kidney transplantation process in Brazil representation with the use of BPMN. We analyzed 2 digital documents that resulted in 2 processes with 45 total of activities and events, 6 organizations involved, and 6 different stages of the process. The constructed representation makes it easier to understand the rules for the business of kidney transplantation and can be used by the health care professionals involved in the various activities within this process. Construction of a representation with language appropriate for the Brazilian lay public is underway.

A rare paracoccidioidomycosis diagnosis in a kidney transplant receptor: case report.

INTRODUCTION: Paracoccidioidomycosis (PCM) is a systemic mycosis of chronic presentation more frequent in adults, which may lead to disseminated severe and lethal forms involving the lungs, skin, lymph nodes, spleen, liver, and lymphoid organs of the digestive tract. Common in Latin America, it is rare in transplanted patients, with few cases described in the literature. PURPOSE: To report a case of a patient who underwent kidney transplant 3 years ago with a pseudotumoral cervical PCM diagnosis. METHODS: A male patient, 45 years old, who underwent kidney transplantation 3 years ago presenting with diarrhea, severe weight loss, and anemia; no breathing complaints. Parasitological stool tests, fecal culture, urine culture, and abdomen USG were performed in order to assess the diarrhea, and were inconclusive. He was treated with antibiotics and antiparasitic drugs with no improvement and continued with weight loss of 15 kg within 3 months. Immunosuppression was changed, with the mycophenolic acid reduced until it was replaced by everolimus. The diarrhea returned to intensify, and there was an increase in the creatinine (from 1.5 to 3.4). He was empirically treated with sulfamethoxazole/trimethoprim, with total remission of the diarrhea. The patient underwent a kidney biopsy, anti-HIV examinations, PCR BK virus, and PCR for Mycobacterium tuberculosis-with no diagnostic conclusion. During his fifth hospitalization (6 months after the beginning of the diagnostic research), presenting a quite compromised general state, loss of 20 kg, anemia, kidney failure, and fever, he developed skin lesions on the legs and a voluminous and hard tumor in the right cervical region. Chest computed tomography was performed, and the tumoral lesions were removed from those regions. He was started on tuberculostatics and underwent a biopsy of the cervical tumoral lesion. RESULT: Biopsy of the cervical tumor showed a fungal infection by paracoccidioidomycosis. The BAAR test of the biopsy was negative. The patient died a few weeks after the diagnosis. CONCLUSION: The association between the organ transplant and PCM is rare and, in unusual clinical presentations, the diagnosis difficulty may compromise a successful treatment.

Application of the intelligent techniques in transplantation databases: a review of articles published in 2009 and 2010.

The replacement of defective organs with healthy ones is an old problem, but only a few years ago was this issue put into practice. Improvements in the whole transplantation process have been increasingly important in clinical practice. In this context are clinical decision support systems (CDSSs), which have reflected a significant amount of work to use mathematical and intelligent techniques. The aim of this article was to present consideration of intelligent techniques used in recent years (2009 and 2010) to analyze organ transplant databases. To this end, we performed a search of the PubMed and Institute for Scientific Information (ISI) Web of Knowledge databases to find articles published in 2009 and 2010 about intelligent techniques applied to transplantation databases. Among 69 retrieved articles, we chose according to inclusion and exclusion criteria. The main techniques were: Artificial Neural Networks (ANN), Logistic Regression (LR), Decision Trees (DT), Markov Models (MM), and Bayesian Networks (BN). Most articles used ANN. Some publications described comparisons between techniques or the use of various techniques together. The use of intelligent techniques to extract knowledge from databases of healthcare is increasingly common. Although authors preferred to use ANN, statistical techniques were equally effective for this enterprise.

Artificial intelligence techniques: predicting necessity for biopsy in renal transplant recipients suspected of acute cellular rejection or nephrotoxicity.

The gold standard for nephrotoxicity and acute cellular rejection (ACR) is a biopsy, an invasive and expensive procedure. More efficient strategies to screen patients for biopsy are important from the clinical and financial points of view. The aim of this study was to evaluate various artificial intelligence techniques to screen for the need for a biopsy among patients suspected of nephrotoxicity or ACR during the first year after renal transplantation. We used classifiers like artificial neural networks (ANN), support vector machines (SVM), and Bayesian inference (BI) to indicate if the clinical course of the event suggestive of the need for a biopsy. Each classifier was evaluated by values of sensitivity and area under the ROC curve (AUC) for each of the classifiers. The technique that showed the best sensitivity value as an indicator for biopsy was SVM with an AUC of 0.79 and an accuracy rate of 79.86%. The results were better than those described in previous works. The accuracy for an indication of biopsy screening was efficient enough to become useful in clinical practice.

Application of artificial neural networks in renal transplantation: classification of nephrotoxicity and acute cellular rejection episodes.

Complications associated with kidney transplantation and immunosuppression can be prevented or treated effectively if diagnosed in the early stages by posttransplant monitoring. One of the major problems is diseases that occur during the first year after kidney transplantation. For this purpose, we used different classifiers to predict events of nephrotoxicity versus acute cellular rejection episodes. The classifiers were evaluated according to values of sensitivity, specificity and area under ROC curves (RCA). The classifier with better accuracy rate for nephrotoxicity achieved the value of 75.68% and RCA classifier reached the accuracy of 80.89%. These results are encouraging, with rates of accuracy and error consistent with work purpose.

Hand-assisted laparoscopic live donor nephrectomy (right-sided approach): experience obtained from 31 cases.

INTRODUCTION: The removal of a donor kidney by laparoscopic nephrectomy is a safe method that is widely used, mainly in left donor nephrectomy. However, for right donor nephrectomy where the right renal vein is short, open surgery has been more frequently described in the literature. OBJECTIVE: Our objective was to describe our experience with 31 renal transplantations using 2 different techniques in right donor nephrectomy. METHOD: In the period ranging from February 2002 to June 2005, we performed, 31 hand-assisted laparoscopic right donor nephrectomies. Twenty-five were performed by the method where the assistant used his hand to assist the surgery and 6 were by the laparoscopic method assisted by the first surgeon. RESULTS: The right donor nephrectomies assisted either by the hand of the assistant or the surgeon showed similar results. All recipients displayed diuresis in the immediate postoperative period. The serum creatinine level at 1 week after transplantation was 1.90 mg/dL (+/-1.55). CONCLUSION: Although the handling techniques are similar, we concluded that laparoscopic nephrectomy assisted by the surgeon is more adequate for right kidney extraction. It can be performed either by a resident doctor or a surgeon of the transplantation team, with or without experience in nephrectomy for transplantation.

Lifespan analysis of 212 transplanted kidney grafts: effects of use of humanized anti-IL-2R monoclonal antibody in graft survival at 1, 3, and 5 years for 108 recipients.

INTRODUCTION: The use of new drugs and new immunosuppressant schemes, as well as induction therapy with anti-IL-2R monoclonal antibody has significantly contributed to prolonged renal graft survival, especially in cadaveric grafts. However, what has led to this improvement has not been defined yet. OBJECTIVE: Analyze the outcome of induction of humanized anti-IL-2R monoclonal antibodies on 1, 3 and 5 year survivals of 212 renal transplants from 1999 to 2005. METHOD: We analyzed the lifespan of grafts using Kaplan-Meier curves, using a significance level of alpha = 0,05 for 212 renal allografts. RESULTS: The global result for 1, 3 and 5 year survival curves of patients who received the induction therapy was 88%, 86% and 86%, and for recipients who did not receive induction was 81%, 81% and 81%, respectively. Likewise, cadaveric donors who received induction displayed 88%, 88% and 88%, and those who did not receive it 62%, 62% and 62% (p = 0,0089). CONCLUSION: Despite the time and the number of transplants using induction therapy being modest, at 1, 3 and 5 years there was an increased lifespan, especially for cadaveric grafts, among patients who received induction, with IL2Ra antibodies.

Hand-assisted laparoscopic nephrectomy versus transperitoneal anterior approach in living donors for renal transplantation.

The objective of this study was to compare two surgical approaches for living donor nephrectomy: transperitoneal anterior approach and the hand-assisted laparoscopic nephrectomy. Between January 2001 and October 2003 we performed 63 kidney transplantations from living donors. The transperitoneal anterior approach was used in 36 cases and the hand-assisted laparoscopic nephrectomy in 27. Outcomes were compared in terms of hospital stay, postoperative analgesia, and graft quality. Mean hospital stay was 4.7 days in the transperitoneal anterior approach group and 3.7 days in the hand-assisted laparoscopic group (P < .005). Postoperative analgesia dosage was significantly lower in the hand-assisted laparoscopic group (P < .001). Surgical complications and graft quality were similar. We concluded that hand-assisted laparoscopic nephrectomy patients had shorter hospital stays and less pain in the postoperative period, with better cosmetic results and equivalent graft quality compared to transperitoneal anterior approach patients.

Renal artery aneurysm in hand-assisted laparoscopic donor nephrectomy: case report.

We report a living donor who underwent laparoscopic nephrectomy using a hand-assisted device (HALD). At preoperative arteriography the donor showed a renal artery aneurysm. The patient was a 37-year-old female, 166 cm height, white, weighing 87 kg, HLA identical to the recipient. HALD was indicated due to the better visualization of renal pedicle and greater security in an obese patient. Renal artery aneurysm is a rare condition, with many possible complications. The method proved to be adequate and safe for donor nephrectomy, despite a renal artery aneurysm.