Kidney transplantation is associated with reduced myocardial fibrosis. A cardiovascular magnetic resonance study with native T1 mapping.

BACKGROUND: The measurement of native T1 through cardiovascular magnetic resonance (CMR) is a noninvasive method of assessing myocardial fibrosis without gadolinium contrast. No studies so far have evaluated native T1 after renal transplantation. The primary aim of the current study is to assess changes in the myocardium native T1 6 months after renal transplantation. METHODS: We prospectively evaluated 44 renal transplant patients with 3 T CMR exams: baseline at the beginning of transplantation and at 6 months after transplantation. RESULTS: The native T1 time was measured in the midventricular septum and decreased significantly from 1331 ± 52 ms at the baseline to 1298 ± 42 ms 6 months after transplantation (p = 0.001). The patients were split into two groups through a two-step cluster algorithm: In cluster-1 (n = 30) the left ventricular (LV) mass index and the prevalence of diabetes were lower. In cluster-2 (n = 14) the LV mass index and diabetes prevalence were higher. Decrease in native T1 values was significant only in the patients in cluster-1 (p = 0.001). CONCLUSIONS: The native myocardial T1 time decreased significantly 6 months after renal transplant, which may be associated with the regression of the reactive fibrosis. The patients with greater baseline LV mass index and the diabetic group did not reach a significant decrease in T1.

Eculizumab interruption in atypical hemolytic uremic syndrome due to shortage: analysis of a Brazilian cohort.

BACKGROUND: The risk of eculizumab therapy discontinuation in patients with atypical hemolytic uremic syndrome (aHUS) is unclear. The main objective of this study was to analyze the risk of aHUS relapse after eculizumab interruption due to drug shortage in Brazil. METHODS: We screened all the registered dialysis centers in Brazil (n = 800), willing to participate in the aHUS Brazilian shortage cohort, through electronic mail and formal invitation by the Brazilian Society of Nephrology. We included patients with aHUS whose eculizumab therapy underwent unplanned discontinuation for at least 30 days between January 1st, 2016 and December 31st, 2019 during the maintenance phase of treatment. Relapse was defined by the development of thrombocytopenia, hemolytic anemia, acute kidney injury or thrombotic microangiopathy (TMA) in a kidney biopsy. RESULTS: We analyzed 25 episodes of exposure to risk of relapse, from 24 patients. Median age was 33 (6-53) years, 18 (72%) were female, 9 (36%) had a functioning renal graft, 5 (20%) were undergoing dialysis. CFH variant was found in 8 (32%) episodes. There were 11 relapses. The risk of relapse was 34%, 44.5% and 58% at 114, 150 and 397 days, respectively. No baseline variable was related to relapse in Cox multivariate analysis, including CFH variant. CONCLUSIONS: In this study, the cumulative incidence of aHUS relapse at 397 days was 58% after eculizumab interruption. The presence of complement variant does not seem to be associated with a higher relapse rate. The eculizumab interruption was deemed not safe, considering that the rate of relapse was high.

Benefits of spirituality and/or religiosity in patients with Chronic Kidney Disease: an integrative review.

OBJECTIVE: Identify and analyze existing evidence regarding the benefits of spirituality and / or religiosity in patients with Chronic Kidney Disease. METHOD: Integrative review carried out through consultation of databases: Latin American and Caribbean Literature in Health Sciences, Scientific Electronic Library Online, US National Library of Medicine and Scopus. The following descriptors were used: chronic kidney disease, spirituality and religion. Primary articles published by December 2017 were included. RESULTS: Twenty-six articles were selected, from which four thematic categories emerged: benefits as a modality of coping, perception of quality of life, mental health and improvement of renal function after transplantation. CONCLUSION: Benefits included those related to situational coping modalities, such as the strengthening of hope, social support and coping with pain; those related to mental health, such as the lower risk of suicide and fewer depressive symptoms; improvement in the perception of quality of life and in renal function after transplantation.

Nephrectomy Versus Embolization of Non-Functioning Renal Graft: A Systematic Review with a Proportional Meta-Analysis.

There is no standardization on the timing of the best approach to treat a non-functioning renal graft. We reviewed the literature and performed a proportional meta-analysis of case series of transplantectomy and embolization for a non-functioning renal graft. The groups were compared for mortality and morbidity outcomes. A total of 2421 patients were included in this review. Of these, 2232 patients underwent transplantectomy and 189 underwent percutaneous embolization. The mortality rate in the nephrectomy group was 4% [95% confidence interval [CI], 2-7%; I²=87%] as compared with 0.1% [95% CI, 0.1-0.5%; I²=0%] in the embolization group. The rates of common morbidities were 18% [95% CI, 13-26%, I²=79.7%] for nephrectomy compared with 1.2% [95% CI, 0.7-2.1%, I²=26.4%] for embolization. The incidence of post-embolization syndrome was 68%, and 20% of patients needed post-embolization nephrectomy. Percutaneous embolization was associated with lower mortality and morbidity rates but also with a high rate of post-embolization syndrome. However, in most cases this complication had easily manageable symptoms. Embolization is a new and attractive technique that can be considered in treating non-functioning renal grafts.

Sirolimus Associated with Tacrolimus at Low Doses in Elderly Kidney Transplant Patients: A Prospective Randomized Controlled Trial.

OBJECTIVES: There is no consensus on the best immunosuppressive regimen for elderly renal transplant recipients. The objective of this study was to assess cytomegalovirus infection incidence and kidney transplant outcomes in elderly recipients treated with mammalian target of rapamycin inhibitors sirolimus/ tacrolimus at low doses compared with those receiving tacrolimus/mycophenolate sodium. MATERIALS AND METHODS: In this single-center prospective randomized study (Trial Registration No. NCT02683291), kidney transplant recipients over 60 years of age were randomly allocated into 2 groups: tacrolimus-sirolimus (21 patients) and tacrolimus-mycophenolate (23 patients). Cytomegalovirus infection rate and patient survival, biopsy-proven acute rejection, and renal function at 12 months were assessed. RESULTS: Cytomegalovirus infection rate was higher in the mycophenolate group (60.9%) than in the sirolimus group (16.7%; P = .004). The rates of biopsy-proven acute rejection, patient survival, graft survival, and estimated glomerular filtration rate over 12 months did not significantly differ between groups. CONCLUSIONS: The incidence of cytomegalovirus infection was significantly lower in the sirolimus group. The use of tacrolimus combined with sirolimus in elderly kidney transplant recipients is safe.

A case report of venous thrombosis after kidney transplantation - We can save the graft? Time is the success factor.

INTRODUCTION: Venous thrombosis is a serious surgical complication that frequently results in loss of kidney graft. CASE PRESENTATION: We report the case of a female patient recipient of a decease kidney transplant that in the tenth postoperative presented with hematuria, graft pain and oliguria. Ultrasound examination was suggestive of venous thrombosis with abnormal doppler waveform pattern and reversal of diastolic flow. She underwent emergency surgical intervention after 2h of diagnosis. The vein thrombus was removed by perfusing the renal graft artery with 1000ml of Euro-Collins solution. The patient evolves with recovery of renal function after 1 week of the procedure DISCUSSION: Similar reports of graft rescue in the vein thrombosis are scarce and that the time of diagnosis to intervention is a determining factor. CONCLUSION: Rapid diagnosis of exactly 2h combined with the early re-operation may be successful in preserving renal graft in cases of venous thrombosis.

Long-term outcomes of the Atypical Hemolytic Uremic Syndrome after kidney transplantation treated with eculizumab as first choice.

INTRODUCTION: The treatment of choice for Atypical Hemolytic Uremic Syndrome (aHUS) is the monoclonal antibody eculizumab. The objective of this study was to assess the efficacy and safety of eculizumab in a cohort of kidney transplant patients suffering from aHUS. METHODS: Description of the prospective cohort of all the patients primarily treated with eculizumab after transplantation and divided into the therapeutic (onset of aHUS after transplantation) and prophylactic use (patients with previous diagnosis of aHUS undergoing kidney transplantation). RESULTS: Seven cases were outlined: five of therapeutic use and two, prophylactic. From the five cases of therapeutic use, there was improvement of the thrombotic microangiopathy in the 48 hours following the start of the drug and no patient experienced relapse during an average follow-up of 21 months in the continuous use of eculizumab (minimum of 6 and maximum of 42 months). One patient died at 6 months, due to Aspergillus infection. From the two cases of prophylactic use, one patient experienced relapsed thrombotic microangiopathy after 4 months and another patient remained asymptomatic after 16 months of follow-up, both on chronic treatment. DISCUSSION: The therapeutic use of eculizumab showed to be effective, with improvement of the microangiopathy parameters and persisting up to the end of the follow-up, without relapses. The additional risk of immunosuppression, leading to opportunistic infections, was well tolerated. The prophylactic use showed to be effective and safe; however, the doses and intervals should be individualized in order to avoid relapsed microangiopathy, especially in patients with factor H mutation.

Effect of the Spiritist "passe" energy therapy in reducing anxiety in volunteers: A randomized controlled trial.

BACKGROUND: In Brazil, one of the most used energy therapies is the Spiritist "passe", which is practiced by Spiritist healers. Although experimental studies have demonstrated the effectiveness of different energy therapies in reducing anxiety and pain, little is known about the effect of the Spiritist "passe" on health outcomes. Therefore, the present study aimed at evaluating the effectiveness of "passe" energy therapy in reducing anxiety symptoms. METHODS/DESIGN: In this prospective, randomized controlled trial, participants were randomly allocated into two groups: Intervention (8 weekly Spiritist "passe" sessions, n=23), and Control (8 weekly sham Spiritist "passe" sessions, n=27). Anxiety was assessed using the Trait Anxiety Inventory (STAI-trait). RESULTS: Of 97 individuals screened, 50 were included in the final analysis. Decreasing STAI-trait anxiety scores were observed in both groups throughout the study (p<0.0001). By the end of the study, 17% and 63% of intervention and control participants, respectively, still met the criterion for anxiety (p=0.001). However, anxiety reduction was more accentuated in the Spiritist "passe" group (p=0.02). CONCLUSION: In this small pilot study, anxiety was more markedly reduced in participants receiving the Spiritist "passe" than in controls, warranting larger trials. TRIAL REGISTRATION: NCT02376959.

Behavioral measures to reduce non-adherence in renal transplant recipients: a prospective randomized controlled trial.

PURPOSE: Solid-organ transplant recipients present a high rate of non-adherence to drug treatment. Few interventional studies have included approaches aimed at increasing adherence. The objective of this study was to evaluate the impact of an educational and behavioral strategy on treatment adherence of kidney transplant recipients. METHODS: In a randomized prospective study, incident renal transplant patients (n = 111) were divided into two groups: control group (received usual transplant patient education) and treatment group (usual transplant patient education plus ten additional weekly 30-min education/counseling sessions about immunosuppressive drugs and behavioral changes). Treatment adherence was assessed using ITAS adherence questionnaire after 3 months. Renal function at 3, 6, and 12 months, and the incidence of transplant rejection were evaluated. RESULTS: The non-adherence rates were 46.4 and 14.5 % in the control and treatment groups (p = 0.001), respectively. The relative risk for non-adherence was 2.59 times (CI 1.38-4.88) higher in the control group. Multivariate analysis demonstrated a 5.84 times (CI 1.8-18.8, p = 0.003) higher risk of non-adherence in the control group. There were no differences in renal function and rejection rates between groups. CONCLUSIONS: A behavioral and educational strategy addressing the patient's perceptions and knowledge about the anti-rejection drugs significantly improved the short-term adherence to immunosuppressive therapy.

Benefits of spirituality and/or religiosity in patients with Chronic Kidney Disease: an integrative review / Beneficios de la espiritualidad y/o religiosidad en pacientes renales crónicos: revisión integrativa / Benefícios da espiritualidade e/ou religiosidade em pacientes renais crônicos: revisão integrativa

ABSTRACT Objective: Identify and analyze existing evidence regarding the benefits of spirituality and / or religiosity in patients with Chronic Kidney Disease. Method: Integrative review carried out through consultation of databases: Latin American and Caribbean Literature in Health Sciences, Scientific Electronic Library Online, US National Library of Medicine and Scopus. The following descriptors were used: chronic kidney disease, spirituality and religion. Primary articles published by December 2017 were included. Results: Twenty-six articles were selected, from which four thematic categories emerged: benefits as a modality of coping, perception of quality of life, mental health and improvement of renal function after transplantation. Conclusion: Benefits included those related to situational coping modalities, such as the strengthening of hope, social support and coping with pain; those related to mental health, such as the lower risk of suicide and fewer depressive symptoms; improvement in the perception of quality of life and in renal function after transplantation.

RESUMEN Objetivo: Identificar y analizar las evidencias existentes referentes a los beneficios de la espiritualidad y/o religiosidad en pacientes renales crónicos. Método: Revisión integrativa realizada por medio de consulta a las bases de datos: Literatura Latino-Americana e do Caribe em Ciência da Saúde, Scientific Electronic Library Online, US National Library of Medicine y Scopus. Se utilizaron los descriptores: enfermedad renal crónica, espiritualidad y religión. Se incluyeron artículos primarios publicados hasta diciembre de 2017. Resultados: Se seleccionaron 26 artículos, de los cuales surgieron cuatro categorías temáticas: beneficios como modalidad de enfrentamiento, en la percepción de la calidad de vida, la salud mental y en la mejora de la función renal post-transplante. Conclusión: Los beneficios incluyeron los relacionados a las modalidades de enfrentamiento situacional, como el fortalecimiento de la esperanza, apoyo social y enfrentamiento del dolor; los relacionados con la salud mental, como el menor riesgo de suicidio y menos síntomas depresivos; mejora en la percepción de la calidad de vida y en la función renal post-transplante.

RESUMO Objetivo: Identificar e analisar as evidências existentes referentes aos benefícios da espiritualidade e/ou religiosidade em pacientes renais crônicos. Método: Revisão integrativa realizada por meio de consulta às bases de dados: Literatura Latino-Americana e do Caribe em Ciência da Saúde, Scientific Electronic Library Online, US National Library of Medicine e Scopus. Utilizaram-se os descritores: Doença Renal Crônica, espiritualidade e religião. Foram incluídos artigos primários publicados até dezembro de 2017. Resultados: Foram selecionados 26 artigos, dos quais emergiram quatro categorias temáticas: benefícios como modalidade de enfrentamento, na percepção da qualidade de vida, à saúde mental e na melhora da função renal pós-transplante. Conclusão: Os benefícios incluíram os relacionados às modalidades de enfrentamento situacional, como o fortalecimento da esperança, apoio social e enfrentamento da dor; os relacionados à saúde mental, como o menor risco de suicídio e menos sintomas depressivos; melhora na percepção da qualidade de vida e na função renal pós-transplante.

Influência da espiritualidade sobre a função renal em pacientes transplantados renais / Influence of spirituality on renal function of kidney transplant patients

Resumo Objetivo: Avaliar a influência da espiritualidade na função renal de pacientes transplantados renais. Métodos: Estudo transversal, conduzido em um hospital de clínicas, público e de grande porte, situado no interior do Estado de São Paulo, Brasil, que incluiu 81 pacientes transplantados renais, entre 30 dias e 60 meses de pós-transplante, seguidos por 12 meses. Com base na Escala de Religiosidade de DUREL os pacientes foram divididos em dois grupos considerando-se a mediana da espiritualidade, sendo estes o grupo espiritualizado (n=52) e o menos espiritualizado (n=29). Para a análise estatística foram utilizados testes indutivos e a análise de modelos lineares mistos, com nível de significância de 5% (p<0,05). Resultados: As características clínicas, de imunossupressão, apoio social, adesão ao tratamento medicamentoso, qualidade de vida e depressão não apresentaram diferenças entre os grupos. A função renal ao longo de um ano foi significativamente maior no grupo espiritualizado a partir do nono mês. Ao fim de 12 meses, a percentagem de pacientes com clearance de creatinina superior a 60ml/min. foi de 61,5% no grupo espiritualizado e 34,5% no grupo menos espiritualizado (p=0,02). A análise multivariada mostrou que o grupo menos espiritualizado apresentou um risco de 4,7 vezes [1,4 - 16,8] maior para pior função renal (p=0,01). Conclusão: Pacientes mais espiritualizados apresentaram melhor função renal no decorrer de um ano de transplante. Esse efeito foi independente de características clínicas, do apoio social e da adesão à terapia imunossupressora. Assim, uma abordagem holística no atendimento, com ênfase no cuidado espiritual, é encorajada.

Abstract Objective: To evaluate influence of spirituality on renal function of kidney transplant patients. Methods: This cross-sectional study included 81 kidney transplant patients who had undergone transplantation between 30 and 60 months previously. Patients were followed up for 12 months. The analysis was carried out in a large public hospital in the countryside of São Paulo, Brazil. Based on the Duke University Religion Index-religiosity and spirituality scale, we divided patients into two groups (spiritualized [n=52] and less spiritualized [n=29]), considering the median spirituality. For statistical analysis, we used inductive tests and analysis with linear mixed models, with a level of significance of 5% (p<0.05). Results: Clinical characteristics, immunosuppression, social support, adherence to drug therapy, quality of life, and depression did not differ between groups. Renal function after 12 months was significantly higher in the spiritualized group from 9 months on. After 12 months, the percentage of patients with creatinine clearance higher than 60 ml/min was 61.5% in the spiritualized group and 34.5% in the less spiritualized group (p=0.02). Multivariate analysis showed that the less spiritualized group had a 4.7 times greater risk [1.4 - 16.8] for worsening in renal function (p=0.01). Conclusion: More spiritualized patients had better renal function after 1 year of transplantation. This result was independent of clinical features, social support, and adherence to immunosuppressive therapy. A holistic approach in health with emphasis on spirituality is encouraged.