[Monitoring and telematic control of people with kidney transplant and suspected COVID-19 infection.] / Seguimiento y control telemático a personas con trasplante renal y sospecha de infección por COVID-19.

OBJECTIVE: People with Kidney Transplantation require immunosuppressant treatments and this classifies them as a population at risk for virus and/or bacterial infections. The objective of the study was to describe the follow-up of transplanted people with suspected COVID19 infection. METHODS: Descriptive, cross-sectional, observational study with prospective follow-up carried out between March and June 2020. Sociodemographic and clinical data were recorded for the assessment, control and follow-up of the cases. The results were expressed with means and standard deviation, median and interquartile range, or frequencies and percentages. The chi-square test was used to compare qualitative variables and the Student's T test to compare quantitative variables with normal distribution. If they did not follow a normal distribution, the Mann Whitney U test was used. The level of statistical significance was established at p<0.05. RESULTS: A total of 56 patients were included, with a mean of 62.73±13.01 years and a median of 39.5 [7.5; 93] months transplanted. 2.48±2.69 calls/patient were made during a period of 3.46±4.41 days. Virtual follow-up was performed with 100% (n=56) and 71.43% (n=40) required hospital admission at some point. 28.57% (n=16) of the people evaluated were managed at home. The PCR test was performed on 85.71% (n=48) of the study population, being positive in 48.21% (n=27). 29.62% (n=8) of the positive cases required invasive mechanical ventilation and 33.33% (n=9) died. The mortality rate in the study population is 4.17 times higher than that presented in the data from the registries in the general population. CONCLUSIONS: According to the mortality data, it is essential to maintain close contact with the main objective of referring the case to the hospital system at the slightest suspicion of complication. Remote monitoring is offered as a positive opportunity for the control of transplant recipients who require close monitoring by the nursing team.

OBJETIVO: Las personas con Trasplante Renal requieren tratamientos con inmunosupresores y esto los clasifica como población de riesgo para infecciones de virus y/o bacterias. El objetivo del estudio fue describir el seguimiento a personas trasplantadas con sospecha de infección por COVID-19. METODOS: Estudio observacional descriptivo de corte transversal con seguimiento prospectivo llevado a cabo entre marzo y junio de 2020. Se registraron datos sociodemográficos y clínicos para la valoración, control y seguimiento de los casos. Los resultados se expresaron con medias y desviación estándar, mediana y rango intercuartílico o frecuencias y porcentajes Se utilizó el test de chi-cuadrado para comparar variables cualitativas y la prueba T de student para comparar variables cuantitativas con distribución normal. Si no seguían una distribución normal se utilizó el test U de Mann Whitney. Se estableció el nivel de significación estadística en p<0,05. RESULTADOS: Se incluyó a un total de 56 pacientes con una media de 62,73± 13,01 años y una mediana de 39,5 [7,5; 93] meses trasplantados. Se realizaron 2,48±2,69 llamadas/paciente durante un periodo de 3,46±4,41 días. Se realizó seguimiento virtual con el 100% (n=56) y el 71,43% (n=40) requirió ingreso hospitalario en algún momento. El 28,57% (n=16) de las personas valoradas se logró controlar en domicilio. Se realizó el test PCR al 85,71% (n=48) de la población estudiada, siendo positivo en el 48,21% (n=27). El 29,62% (n=8) de los casos positivos requirió de ventilación mecánica invasiva y el 33,33% (n=9) falleció. La tasa de mortalidad en la población estudiada es 4,17 veces superior a la presentada en los datos de los registros en población general. CONCLUSIONES: Según el dato de mortalidad, se hace indispensable mantener el contacto estrecho con el objetivo principal de derivar el caso al sistema hospitalario a la menor sospecha de complicación. El seguimiento a distancia se ofrece como una oportunidad positiva para el control de las personas trasplantadas que requieran un seguimiento estrecho por parte del equipo de enfermería.

The Spanish Society of Nephrology (SENEFRO) commentary to the Spain GBD 2016 report: Keeping chronic kidney disease out of sight of health authorities will only magnify the problem.

The Global Burden of Disease (GBD) study measures the health of populations worldwide and by country on an annual basis and aims at helping guide public policy on health issues. The GBD estimates for Spain in 2016 and recent trends in mortality and morbidity from 2006 to 2016 were recently published. According to these estimates, chronic kidney disease was the 8th cause of death in Spain in 2016. Among the top ten causes of death, chronic kidney disease was the fastest growing from 2006 to 2016, after Alzheimer disease. At the current pace of growth, chronic kidney disease is set to become the second cause of death in Spain, after Alzheimer disease, by 2100. Additionally, among major causes of death, chronic kidney disease also ranked second only to Alzheimer as the fastest growing cause of Years Lived with Disability (YLDs) and Disability Adjusted Life Years (DALYs). Public resources devoted to prevention, care and research on kidney disease should be in line with both its current and future burden.

Steroid avoidance or withdrawal for pancreas and pancreas with kidney transplant recipients.

BACKGROUND: Pancreas or kidney-pancreas transplantation improves survival and quality of life for people with type 1 diabetes mellitus and kidney failure. Immunosuppression after transplantation is associated with complications. Steroids have adverse effects on cardiovascular risk factors such as hypertension, hyperglycaemia or hyperlipidaemia, increase risk of infection, obesity, cataracts, myopathy, bone metabolism alterations, dermatologic problems and cushingoid appearance. Whether avoiding steroids changes outcomes is unclear. OBJECTIVES: We aimed to assess the safety and efficacy of steroid early withdrawal (treatment for less than 14 days after transplantation), late withdrawal (after 14 days after transplantation) or steroid avoidance in patients receiving a pancreas (including a vascularized organ) alone (PTA), simultaneous with a kidney (SPK) or after kidney transplantation (PAK). SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register (to 18 June 2014) through contact with the Trials' Search Co-ordinator. We handsearched: reference lists of nephrology textbooks, relevant studies, recent publications and clinical practice guidelines; abstracts from international transplantation society scientific meetings; and sent emails and letters seeking information about unpublished or incomplete studies to known investigators. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or cohort studies of steroid avoidance (including early withdrawal) versus steroid maintenance or versus late withdrawal in pancreas or pancreas with kidney transplant recipients. We defined steroid avoidance as complete avoidance of steroid immunosuppression, early steroid withdrawal as steroid treatment for less than 14 days after transplantation and late withdrawal as steroid withdrawal after 14 days after transplantation. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the retrieved titles and abstracts, and where necessary the full text reports to determine which studies satisfied the inclusion criteria. Authors of included studies were contacted to obtain missing information. Statistical analyses were performed using random effects models and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Cohort studies were not meta-analysed, but their findings summarised descriptively. MAIN RESULTS: Three RCTs enrolling 144 participants met our inclusion criteria. Two compared steroid avoidance versus late steroid withdrawal and one compared late steroid withdrawal versus steroid maintenance. All studies included SPK and only one also included PTA. All studies had an overall moderate risk of bias and presented only short-term results (six to 12 months). Two studies (89 participants) compared steroid avoidance or early steroid withdrawal versus late steroid withdrawal. There was no clear evidence of an impact on mortality (2 studies, 89 participants: RR 1.64, 95% CI 0.21 to 12.75), risk of kidney loss censored for death (2 studies, 89 participants: RR 0.35, 95% CI 0.04 to 3.09), risk of pancreas loss censored for death (2 studies, 89 participants: RR 1.05, 95% CI 0.36 to 3.04), or acute kidney rejection (1 study, 49 participants: RR 2.08, 95% CI 0.20 to 21.50), however results were uncertain and consistent with no difference or important benefit or harm of steroid avoidance/early steroid withdrawal. The study that compared late steroid withdrawal versus steroid maintenance observed no deaths, no graft loss or acute kidney rejection at six months in either group and reported uncertain effects on acute pancreas rejection (RR 0.88, 95% CI 0.06 to 13.35). Of the possible adverse effects only infection was reported by one study. There were significantly more UTIs reported in the late withdrawal group compared to the steroid avoidance group (1 study, 25 patients: RR 0.41, 95% CI 0.26 to 0.66).We also identified 13 cohort studies and one RCT which randomised tacrolimus versus cyclosporin. These studies in general showed that steroid-sparing and withdrawal strategies had benefits in lowering HbAc1 and risk of infections (BK virus and CMV disease) and improved blood pressure control without increasing the risk of rejection. However, two studies found an increased incidence of acute pancreas rejection (HR 2.8, 95% CI 0.89 to 8.81, P = 0.066 in one study and 43.3% in the steroid withdrawal group versus 9.3% in the steroid maintenance, P < 0.05 at three years in the other) and one study found an increased incidence of acute kidney rejection (18.7% in the steroid withdrawal group versus 2.8% in the steroid maintenance, P < 0.05) at three years. AUTHORS' CONCLUSIONS: There is currently insufficient evidence for the benefits and harms of steroid withdrawal in pancreas transplantation in the three RCTs (144 patients) identified. The results showed uncertain results for short-term risk of rejection, mortality, or graft survival in steroid-sparing strategies in a very small number of patients over a short period of follow-up. Overall the data was sparse, so no firm conclusions are possible. Moreover, the 13 observational studies findings generally concur with the evidence found in the RCTs.

Características de la inmunosupresión del receptor de trasplante renal de donante vivo / Immunosuppression in the living donor renal allograft recipient

El trasplante renal de donante vivo permite una mejor individualización de la inmunosupresión sobre la base de criterios clínicos e inmunológicos. Por ejemplo, permite la administración de agentes inmunosupresores días antes del trasplante y prevenir así mejor el rechazo agudo en los casos en los que el riesgo inmunológico lo requiera. Dada la escasa evidencia al respecto, no se recomienda la inmunosupresión previa al trasplante de manera indiscriminada en todos los receptores. En los receptores HLA idénticos relacionados con su donante, se recomienda iniciar la pauta con tacrolimus y un derivado de ácido micofenólico y valorar la suspensión de tacrolimus a partir del sexto mes postrasplante. En las parejas no HLA idénticas, se recomienda inducción con basiliximab, excepto en aquellos de alto riesgo inmunológico, en los que se aconseja timoglobulina. La utilización de un riñón procedente de un donante con criterios expandidos requiere reducir la dosis habitual de tacrolimus para optimizar la función renal. En general, y dependiendo del riesgo inmunológico, se recomienda la suspensión de los esteroides a partir del tercero al sexto mes postrasplante. El trasplante renal de donante vivo con anticuerpos específicos de donante preformados o ABO-incompatible es posible mediante la realización de técnicas de desensibilización como la plasmaféresis o la inmuno adsorción específica, así como la administración de gammaglobulina o rituximab, además de la inmunosupresión convencional...

[Long term results of living donor kidney transplantation: graft and patient survival]. / Resultados a largo plazo del trasplante renal de donante vivo: supervivencia de injerto y receptor.

Donor kidney transplantation's graft and patient survivals are better than cadaver donor's. In Spain, living donor kidney transplantation hardly accounts for 1% of transplant activity in comparison to 60% in United States. Accordingly to bibliography, the experience of the Renal Transplant Unit of the Hospital Clinic de Barcelona has demonstrated better graft and receptor survival for living donor recipients. The analysis of 184 living donor kidney transplants and 1678 cadaver donor transplants performed between 1978 and 2002 showed that graft survival was higher in the group of living donors (p < 0.01). At the same time, graft survival was clearly better in receptors of HLA haploidentical grafts (n=142) (p < 0.05). The introduction of new and better immunosuppressive drugs, as well as better diagnostic and therapeutic management of acute rejection, prophylaxis for infections, and control of complications have contributed to better results. The absence of acute rejection between 1978 and 1983 was 45.1%, between 1984 and 1998 was 57.3% and 84.7% between 1999 and 2003. In conclusion, these results demonstrate better graft and patient survival for living donor kidney transplants in comparison with cadaver donor receptors. Altogether with the low risk involved for donors should incentivate authorities, professionals, and patients to promote these therapeutic option by means of adequate information and wider diffusion. Living donor kidney transplantation should contribute together with cadaver kidney transplantation to lessen our long waiting lists, because they are not excluding options.