Chikungunya Infection in Solid Organ Transplant Recipients.

BACKGROUND: Chikungunya virus (CHIKV) is an emerging mosquito-borne disease that causes acute febrile polyarthralgia and arthritis. CHIKV has spread rapidly to the Americas and, in Brazil, autochthonous cases are increasingly been reported. Solid organ transplant (SOT) recipients who travel to or live in CHIKV endemic areas are under high risk of acquiring the disease. Few data exist regarding the clinical characteristics of CHIKV infections in this population. We report the first case series of CHIKV infection in SOT recipients. METHODS: We retrospectively evaluated 13 cases of CHIKV infection in SOT recipients between January 2016 and December 2016 confirmed by laboratory tests and transplanted in the Renal and Liver Transplant Units of Walter Cantídio University Hospital from Federal University of Ceará. RESULTS: Positive CHIKV serology (enzyme-linked immunosorbent assay immunoglobulin M) was found in all patients (9 kidney and 4 liver transplant recipients). All of these patients had been living in endemic areas for dengue and CHIKV in the past months before the illness. The mean time between transplantation and CHIKV infection was of 7.2 years. Fever presented in 11 (84.6%) patients and 5 (38.5%) presented with a maculopapular rash. All cases had joint symptoms: 11 (84.6%) with symmetrical and peripheral polyarthralgia/polyarthritis and 2 (15.3%) with monoarthralgia/monoarthritis. Six (46%) patients had a joint complaint that lasted 3 months. Two patients had concomitant positive dengue serology (enzyme-linked immunosorbent assay immunoglobulin M). There were no cases of complications or deaths. CONCLUSION: SOT with CHIKV infection seems to have a clinical presentation and evolution similar to those seen in the general population, with no apparent damage to the graft.

Kidney Transplantation Using Gonadal Vein for Venous Anastomosis in Patients With Iliac Vein Thrombosis or Stenosis: A Series of Cases.

BACKGROUND: Kidney transplantation is the treatment of choice for patients with end-stage renal disease. The standard surgery uses the recipient's iliac vessels for vascular anastomosis. Thrombosis and/or stenosis of the iliac vein, which are possible complications of multiple vascular access points for dialysis, can be detected intraoperatively, constituting a surgical challenge. An infrequently reported option is the use of the gonadal vein. OBJECTIVES: This study aims to evaluate the outcomes of venous anastomosis in the gonadal vein in patients with iliac vein thrombosis and/or stenosis submitted to kidney transplantation. METHODS: We reviewed the records of five adult recipients with iliac vein thrombosis and/or stenosis detected intraoperatively during emergency kidney transplantation with deceased donor due to vascular access failure from February 2013 to December 2014. Antithrombotic prophylaxis was not performed. We evaluated the postoperative complications, length of stay, early graft echo-Doppler, and renal function during the first year postoperatively. RESULTS: Delayed graft function occurred in three cases. Two patients developed postoperative infection requiring antibiotics. One patient required reoperation due to post-renal biopsy complications. The mean length of stay was 31.2 days and the mean serum creatinine levels at discharge, at 6 months, and at 12 months postoperatively were 1.42 mg/dL, 0.86 mg/dL, and 0.82 mg/dL, respectively. All patients had normal ultrasonography. There were no losses of graft or deaths during follow-up. CONCLUSION: Venous anastomosis using the gonadal vein in kidney transplantation for patients with iliac vein thrombosis and/or stenosis showed good clinical and surgical results, showing this method to be a viable alternative to venous drainage in these complex patients.

Effects of the Aqueous Extract from Tabebuia roseoalba and Phenolic Acids on Hyperuricemia and Inflammation.

Tabebuia species (Bignoniaceae) have long been used in folk medicine as anti-inflammatory, antirheumatic, antimicrobial, and antitumor. The aim of this study was to investigate if aqueous extract from the leaves (AEL) of Tabebuia roseoalba (Ridl.) Sandwith, Bignoniaceae, and its constituents could be useful to decrease serum uric acid levels and restrain the gout inflammatory process. HPLC analysis identified caffeic acid and chlorogenic acid in AEL. Antihyperuricemic effects and inhibition of liver XOD (xanthine oxidoreductase) by AEL and identified compounds were evaluated in hyperuricemic mice. Anti-inflammatory activity was evaluated on MSU (monosodium urate) crystal-induced paw edema. In addition, AEL antioxidant activity in vitro was evaluated. AEL, caffeic, and chlorogenic acids were able to reduce serum uric acid levels in hyperuricemic mice probably through inhibition of liver xanthine oxidase activity and significantly decreased the paw edema induced by MSU crystals. AEL showed significant antioxidant activity in all evaluated assays. The results show that the AEL of Tabebuia roseoalba can be a promising agent for treatment for gout and inflammatory diseases. We suggest that caffeic and chlorogenic acids may be responsible for the activities demonstrated by the species.

Urinary Tract Infections and Surgical Site Infections due to Carbapenem-Resistant Enterobacteriaceae in Renal Transplant.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) are emerging pathogens. Recent publications have shown that renal transplant recipients are a population at risk for CRE infections. Management of these infections in this population is complex, requiring frequent use of nephrotoxic antimicrobial agents. Differentiating between urinary tract infection (UTI) and surgical site infection (SSI) in renal transplant recipients is sometimes difficult. The aim of this study was to describe CRE UTIs and SSIs in renal transplant recipients and to evaluate the impact of these infections on renal graft and patient survival. RESULTS: Between January 2010 and October 2015, a total of 428 renal transplants were performed; 25 UTIs and 9 SSIs were identified. Median time between transplantation and diagnosis of CRE infection was 26 days; 29 cases (85.29%) were considered early infections. Of the 34 CRE isolates, 100% were sensitive to amikacin and colistin. Polymyxins were the most commonly used antimicrobial agent (27 cases [79.41%]). Nephrotoxicity was found in 4 (15.38%) of 26 cases. Combination therapy was used in 19 cases (55.88%), with a cure rate of 74%; monotherapy was used in 15 cases (44.11%), with a cure rate of 86%. Among the 25 cases of UTI, the cure rate was 100%, and recurrence occurred in 4 cases (16%). Among the 9 cases of SSI, 7 (77.7%) had negative outcomes (nephrectomy or death). CONCLUSIONS: We observed that CRE UTIs had a high therapeutic success rate, low recurrence, and low mortality. However, CRE SSIs were associated with high morbidity and mortality, with high graft loss. Polymyxins and aminoglycosides, despite the risk of nephrotoxicity, had little impact on renal graft function, and are thus a safe therapeutic alternative to treat these infections.

Artery Stenosis of the Renal Graft: Experience of a Center of Northeastern Brazil.

BACKGROUND: Transplant renal artery stenosis (TRAS), the most common vascular complication after transplant (Tx), leads to resistant hypertension, impaired renal function, and even loss of the graft. The purpose of the study was to investigate the prevalence and factors associated with TRAS in northeastern Brazil. METHODS: The study was conducted as a retrospective case-control study in a population of Tx recipients in a renal Tx center in northeastern Brazil. Demographic and clinical characteristics of the recipients and donors, data related to the surgery, laboratory data, and number of anti-hypertensive drugs were assessed. Statistical analysis was performed with the use of SPSS 17.0. RESULTS: A total of 494 of 529 recipients were assessed, of which 24 had TRAS. The prevalence of TRAS was 4.8%. Twelve patients (50%) were men with a mean age of 46.7 ± 13.5 years. The mean time of diagnosis was 89.9 days after Tx. The risk factors associated with TRAS were number of anti-hypertensive drugs ≥2 (odds ratio, 17.0; confidence interval, 4.1 to 70.4; P = .001) and grafting with 2 or more arteries (odds ratio, 8.9; confidence interval, 1.4 to 56.6; P = .021). There was a significant reduction in mean systolic blood pressure (147.1 ± 23.7 to 127.8 ± 15.2 mm Hg, P = .001) and diastolic blood pressure (86.6 ± 13.0 to 77.6 ± 9.4 mm Hg, P = .001) after TRAS repair and in serum creatinine (2.8 ± 2.4 to 1.9 ± 1.8 mg/dL, P = .04). CONCLUSIONS: Grafts with 2 or more arteries are associated with TRAS, as well as patients who use a higher number of anti-hypertensive drugs. TRAS repair was associated with improved blood pressure control and renal function.

The risk factors for and effects of visceral leishmaniasis in graft and renal transplant recipients.

BACKGROUND: The aim of this study was to identify the risk factors for visceral leishmaniasis (VL) in renal transplant recipients and to analyze the impacts of this disease on graft success and patient health. METHODS: This retrospective, case-control study examined 120 renal transplant patients in a VL endemic area. The treatment group included patients (n=20) who developed VL after transplantation, and the control group (n=100) was composed of renal transplant recipients without VL. This study evaluated socioeconomic, demographic, clinical, and laboratory variables. Bivariate analysis and multiple logistic regressions were performed to identify potential risk factors. RESULTS: The average time between transplantation and Leishmania infection in the treatment group was 29.4 months. Seventeen (85%) patients were cured and 3 (15%) died. In 95% of the cases, a myelogram was used for initial identification of Leishmania forms. The significant risk factors for VL in renal transplant recipients were cytomegalovirus infection after transplantation (odds ratio [OR], 5.29; 95% confidence interval [CI], 1.27-21.97) and living with cats (OR, 5.74; 95% CI, 1.15-28.76). Bacterial infection after transplantation (OR, 3.00; 95% CI, 0.96-9.37) and unpaved streets in the neighborhood (OR, 2.14; 95% CI, 0.71-6.43) tended to increase the risk of VL, whereas a negative Rh factor tended to protect against VL (OR, 0.26; 95% CI, 0.06-1.02). CONCLUSION: Cytomegalovirus infection after transplantation and living with cats increased the risk of VL in renal transplant recipients living in VL endemic areas.

Endemic and opportunistic infections in Brazilian solid organ transplant recipients.

OBJECTIVE: To evaluate the frequency and clinical features of endemic and other opportunistic infections in liver or kidney transplant recipients in four transplant centres in different geographical areas of Brazil. METHODS: Retrospective analysis of medical and laboratory records of four transplant centres on endemic and other opportunistic infections in liver or kidney transplant recipients. Analyses were performed with spss statistical software. RESULTS: From 2001 to 2006, 1046 kidney and 708 liver transplants were registered in all centres. The average age was 42 years. Among 82 (4.7%) cases with infections, the most frequent was tuberculosis (2.0%), followed by systemic protozoal infections (0.7%), toxoplasmosis (0.4%) and visceral leishmaniasis (0.3%). Systemic fungal infections occurred in 0.6%, of which 0.4% were cryptococcosis and 0.2% were histoplasmosis. Dengue was the only systemic viral infection and was registered in two cases (0.1%), of which one was classified as the classic form and the other as dengue haemorrhagic fever. Nocardiosis was described in one case (0.05%). The infectious agents most frequently associated with diarrhoea were Blastocystis sp., Schistosoma mansoni and Strongyloides stercoralis. CONCLUSIONS: Opportunistic Infections in transplant patients have a wide spectrum and may vary from asymptomatic to severe infections with high mortality. A better understanding of the epidemiology of endemic pathogens and clinical manifestations can contribute to the establishment of an early diagnosis as well as correct treatment aimed at decreasing morbidity and mortality.

Visceral leishmaniasis in renal transplant recipients: clinical aspects, diagnostic problems, and response to treatment.

Visceral leishmaniasis (VL) is a parasitic infection that uncommonly affects renal transplantation recipients, even in endemic areas. It may be associated with other infections, or masked by these, and may present subclinically and/or atypically for extended periods. The evolution may be particularly severe and diagnosis is often delayed. If not adequately diagnosed and treated, VL can be fatal and so should be suspected in renal transplantation recipients presenting unexplained fever, splenomegaly, and pancytopenia. The authors report 8 cases of VL out of a total of 800 renal transplant recipients from two transplant hospitals centers in Brazil. The clinical, diagnostic, and therapeutic features are reviewed.

Validation of the cause of end-stage renal failure in Afro-Caribbean patients

Afro-caribbean patients are more frequently diagnosed than caucasians as having end-stage renal failure (ESRF) from primary hypertension or diabetic nephropathy. We performed a retrospective study to investigate the diagnostic criteria and to validate the causes of primary renal disease in all new cases of afro-caribbean patients with ESRF who commenced RRT at 3 inner city Hospitals (1991-1995). We collected clinical-pathological data using a standard proforma. Three of us validated the diagnoses. We have identified 142 afro-caribbean patients for inclusion in this study:mean age of 52.3 (15.50, 52.3 percent were male. Renal biopsy was performed in 32 percent of the patients. Before the validation ,the working diagnosis (including that submitted to EDTA) had been diabetic nephropathy 35.2 percent; primary hypertension 18.3 percent; "uncertain" cause 15.5 percent and primary glomerulonephritis 11.3 percent. Following the analysis we ascribed the underlying cause of ESRF to be: diabetic nephropathy 38.7percent (18.2 percent biopsy proven);"uncertain" 21.8 percent; primary glomerulonephritis 10.6 percent (100 percent bx proven); secondary glomerulonephritis 10.6 percent (66.6 percent bx proven); primary hypertension 10.6 percent (40 percent bx proven); pyelonephritis 3.5 percent; polycystic kidneys 2.8 percent. Among the "uncertain" (n=31): twenty four (17 percent) were related to long-standing hypertension but could not be proven as primary disease. Among the diabetic ESRF patients (n=55), only 6 had IDDM while 49 had NIDDM. Twenty percent (28/142) of all patients had accelerated hypertension while 95 percent (134/142) had hypertension at some time during their disease. This study shows that in afro-caribbean patients NIDDM is the main cause of ESRF, whilst the evidence of primary hypertension is over-estimated, the diagnosis is often made on inadequate criteria. Nevertheless primary hypertension plays an important role in progression to ESRF. (AU)

Acceptance for chronic dialysis treatment: insufficient and unequal.

BACKGROUND: Evidence suggests that a number of end-stage renal disease (ESRD) patients die without receiving dialysis. We investigated and compared ESRD patients who died without receiving treatment and those who were accepted for dialysis. METHODS: All patients starting chronic dialysis in 1991 in the city of Sao Paulo and prospectively registered in the Health Secretariat files were studied. From death certificates we obtained data from all patients dying with an underlying cause associated with chronic renal failure. Medical records from a sample of patients who died without receiving dialysis were reviewed. RESULTS: Of 2127 patients, 1582 (74.7%) received dialysis and 545 (25.6%) did not. The best chance of being dialysed occurred in the 20-29 age group. The age groups with the least chance of receiving dialysis were 0-9 years and over 79 years old. The odds ratio (95% Cl) of not receiving dialysis was 12.42 (6.63-23.82) times greater for patients over 60 years old compared to those aged 10-19 years. Patients with renal failure due to congenital diseases, chronic pyelonephritis, unknown cause, and hypertension were less likely to receive dialysis than those with glomerulonephritis or diabetes. CONCLUSIONS: Our results suggest that many ESRD patients die without receiving dialysis. Age and cause of renal disease influence the chance of being accepted for treatment. Restrictions of treatment need to be corrected to guarantee that maintenance dialysis will be accessible to ESRD patients.

Acesso ao tratamento dialítico crônico: deficiente e desigual / Access to chronic dialysis treatment: deficient and unequal

OBJETIVO. Determinar a fraçao de pacientes com insuficiência renal crônica (IRCT) tratada por meio de diálise no Município de Sao Paulo e investigar a influência da idade em relaçao ao acesso a diálise. MATERIAL E MÉTODOS. Foram estudados todos os pacientes que receberam diálise para IRCT durante o ano de 1991, registrados junto à Secretaria de Saúde do Estado. No mesmo ano, foram também coletadas informaçoes dos indivíduos que morreram tendo com causa básica de óbito doença relacionada a insuficiência renal crônica. Estes últimos dados foram obtidos do Serviço Funerário da Prefeitura de Sao Paulo. Cruzando-se os dados destes bancos de dados foi possível descobrir os pacientes que morreram de IRCT sem ter realizado diálise e calcular a fraçao tratada nas diversas faixas etárias. RESULTADOS. De forma global, 25,6 por cento dos pacientes com IRCT nao receberam tratamento. A partir da idade de 40 anos, houve reduçao progressiva e significante (p<0,001) da fraçao de pacientes tratados conforme aumentou a idade. Até os nove anos de idade a percentagem de tratamento também foi reduzida (29 por cento). Indivíduos nas faixas etárias de 60-69 e 70-79 anos apresentaram chance cerca de 5 e 11 vezes maior, respectivamente, de morrer sem receber tratamento dialítico do que aqueles no grupo etário de 20-29 anos. CONCLUSOES. Os autores estimam que pelo menos um quarto dos pacientes com IRCT morreram em Sao Paulo, em 1991, sem ter recebido tratamento dialítico. Idade é um fator importante de discriminaçao para aceitaçao em programas de diálise crônica.

[Access to chronic dialysis treatment: deficient and unequal]. / Acesso ao tratamento dialítico crônico: deficiente e desigual.

OBJECTIVE: To determine the fraction of patients with end-stage renal disease (ESRD) who received dialysis treatment in the city of São Paulo in 1991 and to investigate the influence of age in the access to dialysis. MATERIAL AND METHODS: All patients who received dialysis for ESRD in the city of São Paulo during 1991, and were registered in the Secretary of Health of São Paulo files were included in the study. In the same year, information was also collected on individuals who died having as basic cause of death a disease related to chronic renal failure. These data were obtained from death certificates files. Using simultaneously information from both data bases it was possible to ascertain the patients who died without receiving dialysis and to calculate the treated fraction in several age groups. RESULTS: Overall 25.6% of ESRD patients did not receive treatment. There was a progressive reduction in the fraction of patients treated for those older than 40 years. In children less or equal to 9 years of age the percentage of treatment was also reduced (29%). Individuals in the age groups 60-69 and 70-79 years had a chance about 5 and 11 times greater, respectively, of dying without receiving dialysis than those in the 20-29 years group. CONCLUSIONS: We estimate that at least one fourth of the ESRD patients died in São Paulo in 1991 without receiving dialysis treatment. Age is a major factor of discrimination for acceptance in chronic dialysis programs.