Worse renal transplant outcomes observed among Afro-Brazilian patients on prospective registry data of 2461 renal transplants at least 1 year follow-up.

We present prospective registry data of 2461 (live donor = 1753 and deceased donor = 08) renal transplants performed between 1999 and 2003. All subjects were followed for more than 1 year after transplantation and most were treated with a calcineurin inhibitor and azathioprine. Afro-Brazilian, white, and mixed patients constituted 11% (272), 67.1% (1651), and 14.9% (367) of the population respectively. Mean dialysis time was 42.3 +/- 32.9 months and delayed graft function, occurred in more than 60%. Three-year patient survival rates were 96.3%, 92.8%, and 86.7% for living-related, living-unrelated, and deceased donors, respectively. Corresponding 3-year graft survival rates were 87.3%, 82.1%, and 71.3% and functional graft survival rates were 90.2%, 88.8%, and 81.5%. The poorer transplant outcome observed among Afro-Brazilian patients has been mainly attributed to differences in absorption of cyclosporine, tacrolimus, and mycophenolate mofetil.

The use of cyclosporine modifies the clinical and histopathological presentation of tuberculosis after renal transplantation.

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

Otimizaçäo do uso da ciclosporina em transplante renal / Optimization of the use of cyclosporin in renal transplantation

Avaliamos retrospectivamente estratégias empregadas na otimizaçäo do uso clínico da ciclosporina (CSA) em transplante renal. Baseado na incidência de rejeiçäo aguda nos primeiros 15 dias do transplante, a administraçäo oral da CSA foi superior à infusäo endovenosa constante, apesar dos relatos divergentes na literatura. A falta de monitorizaçäo do nível sanguíneo da CSA e o uso de doses diferentes de esteróides podem ser responsáveis pelo encontro de tais resultados. A minitorizaçäo do nível sanguíneo de CSA foi útil no diagnóstico diferencial de rejeiçäo aguda (RA) e nefrotoxicidade por CSA (NTX), definindo faixas de concentraçäo sangüínea ideais onde o risco de desenvolvimento de algum tipo de disfunçäo foi menor. Esta "faixa terapêutica" ficou entre 200 e 400ng/mL, quando foi utilizado radioimunoensaio tricidado com anticorpo policlonal (PC-CSA-H3), e entre 100 e 250ng/mL, utilizando RIA com anticorpo monoclonal específico (ME-CSA-H3), observando-se uma correlaçäo com um r=0,82 entre os dois métodos em 122 determinaçöes simultâneas. Alteraçöes histológicas encontradas nas biópsias renais de pacientes com RA näo foram diferentes daquelas obtidas de pacientes com NTX, antes ou após 90 dias de transplante. Concluímos que, por näo dispormos, no momento, de um único método com elevada sensibilidade, especificidade e valor preditivo, a monitorizaçäo do nível sanguíneo de CSA associada à biópsia renal é a melhor forma de reduzir a incidência de disfunçäo do enxerto, assegurando uma maior sobrevida, a longo prazo

[Optimization of the use of cyclosporin in renal transplantation]. / Otimização do uso da ciclosporina em transplante renal.

Strategies to optimize the use of cyclosporin A (CSA) in renal transplant were analysed retrospectively. Based on the incidence of acute rejection during the first 15 days of transplant, oral dosing achieved adequate immunosuppression earlier than constant intravenous infusion of CSA. The lack of CSA blood monitoring and the use of different steroid doses in this period could be responsible for these conflicting results. The differential diagnosis between acute rejection (AR) and CSA nephrotoxicity (NX) during the first year of transplant was made based on clinical findings, CSA levels and histological evaluation. Therapeutic CSA concentration range between 200 and 400 ng/mL, using radioimmunoassay with polyclonal antibodies, and between 100 and 250 ng/mL, using specific monoclonal antibodies, were found. A correlation of r = 0.82 between these two methods were obtained in 122 simultaneous dosages. Histological abnormalities found in biopsies from patients with AR were not different from those obtained from patients with NX, before and after 90 days of transplant. The conclusion was drawn that the therapeutic CSA monitoring associated with histological evaluation can reduce the incidence of renal dysfunction and promote a long-term and stable graft survival.

[Estimation of the number of potential organ donors in the city of São Paulo]. / Estimativa do número de potenciais doadores de órgãos na cidade de Sáo Paulo.

BACKGROUND: There is a concept that the small number of transplants is due to the shortage of donors or the refusal of the next of kin to make to donation. In order to evaluate the potential number of donors in São Paulo the autopsies performed at the Forensic Medical Institute (IML) were studied during 1990 and 1991. MATERIAL AND METHOD: The autopsies carried out during 1990 and 1991 were studied. During the same period we also analysed the reports of possible donors received by the organ searching team of the Escola Paulista de Medicina (EPM). RESULTS: During 1990 and 1991, 11601 and 11607 autopsies were respectively carried out (32 autopsies/day). The analysis of 500 autopsies during 10/90 and of 1039 during 05/91 showed that 27% had a traumatic brain injury (TBI) as the sole cause of death and 70% were cared for in a hospital. From 01/90 to 12/91 the organ searching team of the EPM received reports of 296 possible donors. Of the 296 reports, 219 families were contacted and 59% authorized the donation. CONCLUSION: Considering the number of deaths exclusively caused by TBI that passed through any hospital and the rate of donations obtained by our team, there is a number of potential donors in São Paulo sufficient to saturate the working capacity of all teams, if the seeking system is efficient.