Epidemiology of tuberculosis after kidney transplantation in a developing country.

BACKGROUND: Tuberculosis (TB) is a great challenge in kidney transplantation, and is often associated with high morbidity and mortality. The aim of this study was to evaluate the epidemiology, clinical manifestations, and impact of TB in kidney transplant (KT) recipients. METHODS: We performed a retrospective analysis of a cohort of adult KT recipients from 2000 to 2012, with follow-up until July 2014. RESULTS: Among the 1737 KT recipients evaluated, 60 developed TB: a 5% cumulative incidence, and an incidence rate of 589.4 cases/100,000 patient-years. Median time to diagnosis was 13.4 months, with 40% of the cases occurring in the first year. New-onset diabetes was significantly associated with post-transplant TB (P = 0.018). Pulmonary TB represented 78% of the cases, including disseminated disease. Two patients received latent TB treatment and developed active infection. TB was associated with a significant reduction in patient and graft survival (74% vs. 90.2% in 5 years for patient survival, P = 0.001; and 58.6% vs. 80.2% in 5 years for graft survival, P < 0.001). Death and graft loss occurred in the first 6 months after diagnosis in one-third of the patients, 38.8% of them with disseminated disease. Disseminated disease was significantly associated with mortality compared to local disease (41.8% vs. 9.7%, P = 0.035). CONCLUSION: TB continues to be a great challenge in KT, especially in developing countries, with significant impact on patient and graft survival.

Acute kidney injury after liver transplantation: incidence and mortality.

INTRODUCTION: Patients undergoing orthotopic liver transplantation often present with acute kidney injury (AKI) in the postoperative period. It has been associated with a greater number of complications and high mortality rates. The goal of this study was to determine the incidence of AKI during the early posttransplant period and mortality in patients undergoing orthotopic liver transplantation in our hospital. PATIENTS AND METHODS: In this retrospective cohort study, we reviewed the medical records of all patients aged >18 years undergoing liver transplantation from April 2008 to April 2011. The exclusion criteria were a glomerular filtration rate (estimated by using the Modification of Diet in Renal Disease formula) <60 mL/min/1.73 m(2) or AKI at the time of transplantation. AKI was defined as an increase ≥50% from preoperative baseline serum creatinine levels during the hospitalization period. RESULTS: Of 113 selected patients, 78 (69%) were male. The mean age was 54.03 ± 9.38 years. The mean preoperative baseline creatinine level was 0.94 ± 0.15 mg/dL, and the estimated glomerular filtration rate was 87.09 ± 19.67 mL/min/1.73 m(2). The mean calculated Model for End-Stage Liver Disease score was 13. Hepatitis C serology was present in 70.8%, hepatitis B in 11.5%, hepatocellular carcinoma in 75.2%, and alcohol abuse in 31.9% of patients. The incidence of AKI was 56.6% (64 of 113 patients). The main risk factors for AKI were Model for End-Stage Liver Disease score and diuretic use at baseline. Renal replacement therapy (RRT) was performed in 19.5% (22 of 113) of patients. The hospital mortality rate in the group with AKI was 25% (16 of 64 patients) and 6.1% (3 of 49 patients) between patients without AKI (odds ratio, 5.11 [confidence interval, 1.39-18.7]; P < .01]. Among patients who underwent RRT, the in-hospital mortality rate was 54.5% (12 of 22 patients) compared with 7.7% (7 of 91 patients) from the other remaining patient cohort (odds ratio, 14.40 [confidence interval, 4.60-45.00]; P < .01). CONCLUSIONS: There was a high incidence of AKI in patients undergoing liver transplantation and an increased risk of mortality among patients who needed RRT.

Educational program of organ donation and transplantation at medical school.

A favorable attitude of health professionals to organ donation can positively influence the decision of families of potential donors. By increasing health professionals knowledge about donation and transplantation and qualifying them to disseminate information, education has produced a positive response to increase the insufficient number of donors. Educating students early in their careers may become crucial in this setting. In order to supply the necessary information about the process of donation and transplantation, a medical school in association with the Hospital Transplant Coordination Department created an educational program of organ donation and transplantation. This course is intended for medical, biomedical, and nutrition students. The objective of our program is to supply basic knowledge about organ donation and transplantation to students of medicine, nutrition, and biomedicine and to enhance their commitment to this process. Each semester, 50 to 90 students are enrolled in the course, which involves a total of 25 hours. Various aspects are approached such as brain death, donor management, political and legal aspects of donation, and skin, lung, bone marrow, heart, pancreas, liver, and kidney transplantation. Between March 2006 and June 2007, three courses were carried out and 200 students were trained. The students evaluated the course and rated it as excellent, concluding that it contributed to their education. Their attitude toward organ donation and transplantation was strongly positive at the end of the course. This project aims to educate and stimulate students in the process of organ donation and transplantation and should be implemented in other medical schools.

Kidney transplantation with Belzer or Custodiol solution: a randomized prospective study.

PURPOSE: The purpose of this study was to compare the Belzer vs Custodiol solutions for cadaveric kidney perfusion in relation to delayed graft function, renal function, acute rejection episodes, and patient and graft survivals. METHODS: This randomized prospective study included 42 kidneys and 9 simultaneous kidney and pancreas recipients from December 2002 to February 2004, namely 24 in the Custodiol arm and 27 in the Belzer arm. We analyzed delayed graft function frequency, acute rejection episodes (biopsy proven), renal function (creatinine at 1, 6, and 12 months), as well as graft and patient survivals. Categorical and continuous variables were evaluated as appropriate. RESULTS: We failed to observe a difference in the immunosuppressant drug protocol, cold ischemia time, or mean recipient or donor age. The prevalence of delayed graft function was 63% among the Belzer arm, and 50% among the Custodiol arm (P = NS). The renal function was the same in both arms at 1, 6, and 12 months. The graft survival after 3 months was 94% among the Belzer group (death from sepsis), and 95% among the Custodiol group (nonfunctioning graft). At 1 year, the results were 78% among the Belzer group (4 deaths from cardiovascular or infectious complications and 2 graft losses), and 79% among the Custodiol group (3 deaths, 1 primary nonfunctioning graft, and 1 graft loss; P = NS). After 12 months follow-up, patient survival was 84% among the Belzer group, and 86% among the Custodiol group. In the first year, the incidences of biopsy-proven acute rejection episodes were 37% among the Belzer group, and 33% among the Custodiol group. CONCLUSION: Custodiol solution achieved similar results compared with Belzer solution.

Pregnancy outcome after renal transplantation.

AIMS: The aim of our study was to evaluate the frequency and the outcome of pregnancies in renal transplant recipients at our center. METHODS: This study involved the retrospective analysis of 405 childbearing female renal recipients for presence of risk factors, the outcome of pregnancy, and maternal and fetal complications. RESULTS: Fourty-four pregnancies occurred in 41 patients (10.8%). Mean age at transplantation was 23.6 +/- 6.3 years (range, 12-38 years). Only in 5 pregnancies were there no risk factors. In 13 (29.5%) pregnancies, the previous creatinine level was >1.5 mg/dL, in 16 (36.45%), proteinuria was >500 mg/24 hours; 29 (65.9%) were hypertensive; 14 (31.8%) had a time between transplantation and pregnancy less than 2 years (mean time, 35.5 +/- 30.9 months; range, 3-120 months). The outcomes were 27 (61.4%; 11 term and 16 premature delivery) successful pregnancies, 6 (13.6%) spontaneous abortions, 10 (22.7%) therapeutic abortions, and 1 (3.2%) fetal death. Pre-eclampsia occurred in 9 (20.4%) pregnancies and eclampsia in 1 (2.2%). The mean weight of the offspring was 2195 +/- 490 g (range, 1300- 2980 g). There were 2 cases of acute fetal distress and 1 oligodramnios. Median creatinine level was 1.0 (range, 0.4-3.0) mg/dL before conception and 1.2 (range, 0.7-9.0) mg/dL 6 month after pregnancy (P <.001). The long-term patient and graft survival rates were similar for pregnant versus nonpregnant recipients in the childbearing age. CONCLUSION: Most pregnancies were successful, although the premature delivery rate was high (36.4%). Only 5 conceptions occurred in the absence of risk factors. Pregnancy did not impair the patient and graft survival during long-term follow-up.

Immunosuppression in pancreas transplantation: mycophenolate mofetil versus sirolimus.

The use of mycophenolate mofetil (MMF) in pancreas transplantation has increased graft survival and decreased the incidence of acute rejections episodes (ARE), regardless of the choice of calcineurin inhibitor. The combination of MMF with tacrolimus (TAC) is the most common protocol, it is considered the gold standard for new protocols. In the last few years, there have been reports of a small number of patients treated with sirolimus (RAPA), usually combined with TAC. Patient and pancreas survival rates as well as the incidence of ARE were similar to protocols with TAC and MMF. Twenty simultaneous pancreas and kidney (SPK) transplantations were performed using an immunosuppressive protocol of TAC, RAPA, and steroids (STE) after 2000. The incidence of ARE was 25%; all episodes responded to STE. Only 2 patients (10%) displayed hypercholesterolemia requiring treatment with statins. The use of RAPA as an alternative to MMF is promising, although presently one with limited experience. The combination of MMF and RAPA with or without a calcineurin inhibitor is an option to be evaluated in the future.

CAPD in southern Brazil: an epidemiological study.

There are many studies on the performance of continuous ambulatory peritoneal dialysis (CAPD) in developed countries, but studies in the third world are scarce. The aim of this study is to analyze CAPD experience in the southernmost state of Brazil (Rio Grande do Sul, RS). Records were obtained from the Health Secretary of RS to assemble a cohort of all patients treated with CAPD. Another cohort study followed all patients initiating treatment for uremia in 1993 in the state capital, Porto Alegre, and compared CAPD, hemodialysis, and transplanted patients. In RS, 1316 patients (50.4% male, mean age 45.9 years) were treated in 40 CAPD programs. Despite the initial growth of the CAPD population, it subsequently leveled off. Survival was 78.6% and 40.7% in years 1 and 5, being worse for initial patients of each program, infants, and elders. Technique survival was 57.4% and 10.1% at years 1 and 5. Patients interrupting treatment for any reason had a higher chance of dropout. In Porto Alegre, 294 patients started dialysis during 1993; 21 performed CAPD, 44 had a transplant, and the others were hemodialyzed. Children were treated mostly by CAPD. CAPD patients had less diabetes and ischemic heart disease and received more transplants. Their adjusted actuarial survival (100% year 1; 67% year 3) was no different than hemodialysis. CAPD is not a popular form of renal therapy in RS, and dropout rates are significant.