RESUMO
BACKGROUND: There is no robust evidence-based data for ABO-incompatible kidney transplantation (ABOiKT) from emerging countries. METHODS: Data from 1759 living donor ABOiKT and 33 157 ABO-compatible kidney transplantations (ABOcKT) performed in India between March 5, 2011, and July 2, 2022, were included in this retrospective, multicenter (n = 25) study. The primary outcomes included management protocols, mortality, graft loss, and biopsy-proven acute rejection (BPAR). RESULTS: Protocol included rituximab 100 (232 [13.18%]), 200 (877 [49.85%]), and 500 mg (569 [32.34%]); immunoadsorption (IA) (145 [8.24%]), IVIG (663 [37.69%]), and no induction 200 (11.37%). Mortality, graft loss, and BPAR were reported in 167 (9.49%), 136 (7.73%), and 228 (12.96%) patients, respectively, over a median follow-up of 36.3 mo. In cox proportional hazard model, mortality was higher with IA (hazard ratio [HR]: 2.53 [1.62-3.97]; P < 0.001), BPAR (HR: 1.83 [1.25-2.69]; P = 0.0020), and graft loss (HR: 1.66 [1.05-2.64]; P = 0.0310); improved graft survival was associated with IVIG (HR: 0.44 [0.26-0.72]; P = 0.0010); higher BPAR was reported with conventional tube method (HR: 3.22 [1.9-5.46]; P < 0.0001) and IA use (HR: 2 [1.37-2.92]; P < 0.0001), whereas lower BPAR was reported in the prepandemic era (HR: 0.61 [0.43-0.88]; P = 0.008). Primary outcomes were not associated with rituximab dosing or high preconditioning/presurgery anti-A/anti-B titers. Incidence of overall infection 306 (17.39%), cytomegalovirus 66 (3.75%), and BK virus polyoma virus 20 (1.13%) was low. In unmatched univariate analysis, the outcomes between ABOiKT and ABOcKT were comparable. CONCLUSIONS: Our largest multicenter study on ABOiKT provides insights into various protocols and management strategies with results comparable to those of ABOcKT.
Assuntos
Transplante de Rim , Humanos , Transplante de Rim/métodos , Rituximab/uso terapêutico , Imunossupressores/uso terapêutico , Estudos Retrospectivos , Imunoglobulinas Intravenosas/uso terapêutico , Incompatibilidade de Grupos Sanguíneos , Sistema ABO de Grupos Sanguíneos , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Doadores Vivos , Estudos Multicêntricos como AssuntoRESUMO
Data are scarce regarding the prevalence of frailty in elderly patients undergoing maintenance hemodialysis (HD) in India. We conducted a cross-sectional observational study aimed to study the prevalence of frailty and cognitive dysfunction in patients aged 75 years or more undergoing maintenance HD in three tertiary care hospitals and associated stand-alone dialysis centers in North Kerala. Frailty was ascertained by two methods. In method 1 (physical performance measurement based), dichotomous scoring (0 or 1) of five domains, namely weight loss, exhaustion, low physical activity, weak grip, and slow walking, was done, and a score of 3/5 was used to define frailty. In method 2 (self-report measure based), scores on the Medical Outcomes Study Short-Form 36-item Questionnaire (SF-36) physical function domain were used instead of hand grip strength and walking speed, and a score of <75 was defined as meeting the criteria for weakness and slow walking. Cognitive function was documented using the Montreal Cognitive Assessment Instrument. A total of 899 patients were screened, of whom 44 were aged 75 years or more and 39 met the criteria for inclusion. The majority (n = 31, 79.5%) had ages between 75 and 80 years and were male. Dialysis vintage was <1 year in 15.4%, 1-3 years in 51.3%, and >3 years in 33.3% of patients. Frailty was documented in 22 (56.4%) patients by method 1 and in 25 (64.1%) by method 2. There was a statistically significant difference between the two methods in documenting frailty (P < 0.001, Chi-square test). Cognitive impairment was present in 89.7% of patients and significantly associated with frailty (P < 0.001, Fisher's exact test). Frailty and cognitive dysfunction are highly prevalent in elderly people undergoing maintenance HD in North Kerala. Physical performance and self-report measure-based methods correlate well in frailty documentation.
Assuntos
Disfunção Cognitiva , Fragilidade , Diálise Renal/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/complicações , Disfunção Cognitiva/epidemiologia , Estudos Transversais , Feminino , Idoso Fragilizado , Fragilidade/complicações , Fragilidade/epidemiologia , Humanos , Índia/epidemiologia , Masculino , PrevalênciaRESUMO
Transplantation across the ABO blood group (ABOI-Tx) has facilitated to increase in donor pool for living donor kidney transplantation. Increased risk of rejection despite augmented immunosuppression has been the concern for many transplant programs in initiating an ABOI-TX program. The benefits of induction immunosuppression on long-term graft survival in immunologically low-risk individuals are still not clear. Increased immunosuppression of ABOI-Tx recipients before transplantation could provide an opportunity to transplant without induction with IL2-R blockers or Lymphocyte depleting agents. The aim of our study is to analyze the outcome of our series of 25 consecutive ABOI-Tx patients who underwent transplantation without routine thymoglobulin or IL2R-blocker induction. Our study is a prospective observational study for the first 25 consecutive patients who had undergone ABOI-Tx from two tertiary care centers in Kerala, India, having the same IS protocol. Anti-A and anti-B titers ≤1:512 by Gel-method (Biorad) were accepted for desensitization. Patients underwent CDC-crossmatch, Flow-crossmatch, and Luminex-anti-HLA-antibody-screen. Desensitization regimen included- Rituximab 200 mg on Day-21, Triple IS Prednisolone 10 mg, mycophenolate mofetil 1000 mg, and Tacrolimus 0.06 mg/bodywt from Day-14 and Plasma-exchange (PLEX) 3-4 sessions from day -7 to attain titer of 1:8 before transplantation. Transplantation was done without induction IS. Twenty-five patients underwent ABOI-Tx from both centers. Twenty recipients were male. The average age was 34.5 ± 8 years with follow-up of 503 ± 120 days. Eight donors were spouse, 13 were parents and three siblings. The average age of the donor was 46.3 ± 10.5 years. Twenty-two patients have normal functioning transplant with creatinine 1.23 ± 0.2 mg/dL. Kaplan-Meier analysis showed patient survival of 91.2% and death censored graft survival of 95.6% at 36 months. Two patients were lost; one on the postoperative day (POD)-3 due to ACS and second on POD-22 due to sepsis. One graft loss occurred due to posttransplant HUS. Of the functioning 22 allograft-recipients, one had cellular rejection, which resolved with pulse steroids; one developed HUS due to CNI, which recovered with PLEX and switch to non-CNI based IS. One patient developed AMR on POD-4, which was completely reversed with PLEX, intravenous immunoglobulin (IVIG), and augmentation of IS. Three patients had CMV viremia and another three patients had BKV viremia, all resolved with treatment and tailoring of IS. Achieving acceptable anti-A/B titers prior to transplantation is the most critical step in ABOI-Tx. Avoidance of induction IS can reduce cost and infectious complications. Our data showed that there is no increased incidence of rejections in the first post-transplant year for immunologically low-risk individuals from histocompatibility standpoint undergoing ABOI-Tx without induction immunosuppression.
Assuntos
Sistema ABO de Grupos Sanguíneos/imunologia , Incompatibilidade de Grupos Sanguíneos , Sobrevivência de Enxerto/fisiologia , Terapia de Imunossupressão/métodos , Transplante de Rim/métodos , Adulto , Seleção do Doador , Feminino , Humanos , Rim/patologia , Rim/cirurgia , Transplante de Rim/efeitos adversos , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos ProspectivosRESUMO
Renal replacement therapy in India is predominantly a private health-care-driven initiative making it an expensive treatment option due to high out-of-pocket expenditures. Moreover, with the rapid increase in the number of chronic kidney disease patients requiring dialysis, hemodialysis units (HDUs) are getting saturated. Community "stand-alone" dialysis centers could be an important alternative to HDUs in meeting the growing demand in an affordable model. The aim of this study was to find hemodialysis (HD) delivery in "stand-alone" dialysis units (SAUs) with respect to expanding coverage, patient costs, and patient safety safeguards. The total number of HD sessions was collected at three points. The information regarding patient safety safeguards at SAUs and impact of SAUs on patient costs were collected by interviews and from hospital records. There was 11.5 times increase in HD sessions from 2008 to 2017, out of which 75.3% was provided at SAUs. Following objective clinical and safety measures, high-quality dialysis was delivered at SAUs and it significantly reduced the mean patient cost of treatment per session.