RESUMO
Pre-existing occlusion of the inferior vena cava may complicate renal transplantation. Suppurative abdominal wall phlebitis following renal transplantation was diagnosed in a patient with pre-existing thrombosis of the inferior vena cava of unknown cause. The phlebitis developed in the subcutaneous collateral veins of the abdominal wall contra-laterally to the renal transplant. Cultures from abdominal wall micro-abscesses yielded Prevotella bivia as the causative agent. This complication has not been described before in the context of renal transplantation. The pathogenesis and management of this serious complication are discussed in this paper.
Assuntos
Parede Abdominal , Infecções por Bacteroidaceae/diagnóstico , Transplante de Rim , Flebite/diagnóstico , Prevotella/isolamento & purificação , Veia Cava Inferior/patologia , Parede Abdominal/patologia , Infecções por Bacteroidaceae/tratamento farmacológico , Infecções por Bacteroidaceae/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Flebite/tratamento farmacológico , Flebite/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagemRESUMO
Rabbit anti-thymocyte globulin (rATG) induces a long-lasting lymphocytopenia. CD4(+) T cells remain depleted for up to 2 years, whereas the CD8(+) T cell compartment is refilled rapidly by highly differentiated CD27(-) CD45RA(+) CD57(+) effector-type cells. Because the presence of these highly differentiated CD8(+) T cells has been associated with cytomegalovirus (CMV) infection, we questioned to what extent restoration of CMV T cell immunity contributes to the re-emergence of T cells following rATG treatment. We compared T cell repopulation in six CMV-seropositive patients with CMV reactivation (reactivating CMV(+) ) to that in three CMV(+) patients without reactivation (non-reactivating CMV(+) ), and to that in three CMV-seronegative recipients receiving a kidney from a CMV-seronegative donor (CMV(-/-) ). All patients received rATG because of acute allograft rejection. Total CD4 and CD8 counts, frequency and phenotype of virus-specific CD8(+) T cells were determined. In reactivating CMV(+) patients, total CD8(+) T cells reappeared rapidly, whereas in non-reactivating CMV(+) patients they lagged behind. In CMV(-/-) patients, CD8(+) T cell counts had not yet reached pretransplant levels after 2 years. CMV reactivation was indeed followed by a progressive accumulation of CMV-specific CD8(+) T cells. During lymphocytopenia following rATG treatment, serum interleukin (IL)-7 levels were elevated. Although this was most prominent in the CMV-seronegative patients, it did not result in an advantage in T cell repopulation in these patients. Repopulated CD8(+) T cells showed increased skewing in their Vß repertoire in both CMV(-/-) and reactivating CMV-seropositive patients. We conclude that rapid T cell repopulation following rATG treatment is driven mainly by CMV.
Assuntos
Soro Antilinfocitário/imunologia , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD8-Positivos/imunologia , Infecções por Citomegalovirus/imunologia , Citomegalovirus/fisiologia , Imunossupressores/imunologia , Linfopenia/imunologia , Complicações Pós-Operatórias/imunologia , Adulto , Animais , Soro Antilinfocitário/uso terapêutico , Antivirais/uso terapêutico , Infecções por Citomegalovirus/tratamento farmacológico , Infecções por Citomegalovirus/virologia , DNA Viral/sangue , Feminino , Ganciclovir/análogos & derivados , Ganciclovir/uso terapêutico , Rearranjo Gênico da Cadeia beta dos Receptores de Antígenos dos Linfócitos T , Rejeição de Enxerto/tratamento farmacológico , Humanos , Imunossupressores/uso terapêutico , Interleucina-7/sangue , Transplante de Rim , Contagem de Linfócitos , Linfopenia/patologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/virologia , Coelhos , Valganciclovir , Viremia/tratamento farmacológico , Viremia/imunologia , Viremia/virologia , Ativação Viral , Adulto JovemRESUMO
Several assays to measure pre-existing allospecific T cell immunity in renal transplant candidates have been developed in the past years. In 46 patients, we used flow cytometry-based mixed lymphocyte culture to measure the precursor frequency and phenotype of alloreactive T cells before renal transplantation, using donor-specific or third-party cells for allostimulation. Allostimulation induced up-regulation of co-stimulatory molecules, chemokine receptors relevant for migration of T cells into the graft and effector proteins. Recipients prone for acute rejection had a higher precursor frequency of alloreactive CD8(+) T cells and a lower percentage of interleukin (IL)-7Rα expressing alloreactive CD8(+) T cells than non-rejectors. These data point to quantitative and qualitative differences between T cells of patients who will experience acute cellular rejection episodes from those who will not.
Assuntos
Transplante de Rim/imunologia , Linfócitos T/imunologia , Adulto , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD4-Positivos/metabolismo , Linfócitos T CD8-Positivos/imunologia , Linfócitos T CD8-Positivos/metabolismo , Feminino , Rejeição de Enxerto/tratamento farmacológico , Rejeição de Enxerto/imunologia , Humanos , Imunofenotipagem , Interferon gama/metabolismo , Subunidade alfa de Receptor de Interleucina-15/metabolismo , Subunidade alfa de Receptor de Interleucina-2/metabolismo , Ativação Linfocitária/imunologia , Contagem de Linfócitos , Teste de Cultura Mista de Linfócitos , Masculino , Pessoa de Meia-Idade , Receptores de Quimiocinas/metabolismo , Receptores de Citocinas/metabolismo , Receptores de Interleucina-7/metabolismo , Doadores de Tecidos , Transplante Homólogo/imunologiaRESUMO
INTRODUCTION: The incidence of urological complications after renal transplantation ranges from 2.5 to 30%. Often surgical revision is necessary. The risk factors for surgical revision and which surgical techniques to apply are not elucidated. This study investigates the outcome and risk factors for surgical revision of the ureterocystostomy. MATERIALS AND METHODS: Between January 1995 and March 2009, 1,157 consecutive kidney transplantations were performed. All patient charts and surgical reports were reviewed. RESULTS: Urological complications occurred in 142 (12.3%) patients. In 60 patients (5.2%) surgical revision was necessary. Of these 60 patients, 43 (71.7%) received neoureterocystostomy, 10 (16.7%) ureteropyelostomy reconstruction and 7 (11.7%) other techniques. Independent risk factors for surgical revision were donor ureteral reconstruction (odds ratio (OR) 48.66, 95% confidence interval (CI) 5.01-472.97), recipient age <18 years (OR 4.85, 95% CI 1.50-15.72) and delayed graft function (OR 2.70, 95% CI 1.36-5.36). Ureteral stenting was a protective factor for surgical revision (OR 0.30, 95% CI 0.12-0.81). The urological complication rates after neoureterocystostomy, ureteropyelostomy reconstruction and other techniques were 16, 0 and 0%, respectively. The overall surgical success rate was 92%. CONCLUSIONS: Ureteral stenting, recipient age, delayed graft function and perioperative ureteral reconstruction are significant factors associated with surgical revision of the ureterocystostomy. Surgical revision of the ureterocystostomy is a successful therapy with a low recurrence rate.
Assuntos
Cistostomia/efeitos adversos , Transplante de Rim/efeitos adversos , Procedimentos de Cirurgia Plástica/efeitos adversos , Ureter/cirurgia , Ureterostomia/efeitos adversos , Doenças Urológicas/etiologia , Adolescente , Adulto , Função Retardada do Enxerto/etiologia , Feminino , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Países Baixos , Razão de Chances , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Doenças Urológicas/cirurgia , Adulto JovemRESUMO
In 4 patients, 3 women aged 63, 17 and 43 years, and a man aged 67 years, lidocain was used as a local anaesthetic for a transthoracic esophageal fundoplication (first patient), severe painful gonarthrosis (fourth patient) and legal abortion (second and third patients). All patients suffered from systemic toxicity as a result, a rare complication. They all had an uneventful recovery, except for the second patient who died from adult respiratory distress syndrome after two weeks in the intensive care unit. The second and third patients had inadvertently been given a solution of lidocain that was too strong (10% instead of 1%). The presenting symptoms of systemic toxicity include numbness of the tongue, dizziness, tinnitus, visual disturbances, muscle spasms, convulsions, reduced consciousness, coma, and respiratory arrest. Physicians who use lidocain as a local anaesthetic should be aware of its systemic toxicity.
Assuntos
Anestésicos Locais/efeitos adversos , Lidocaína/efeitos adversos , Adolescente , Adulto , Idoso , Período de Recuperação da Anestesia , Anestésicos Locais/administração & dosagem , Relação Dose-Resposta a Droga , Emergências , Evolução Fatal , Feminino , Humanos , Lidocaína/administração & dosagem , Masculino , Pessoa de Meia-Idade , Transtornos Respiratórios/induzido quimicamenteRESUMO
BACKGROUND: Hypertension in kidney transplant recipients jeopardises graft and patient survival. Guidelines suggest blood pressure targets of ≤130/80 mmHg and sodium intake <90 mmol/day. METHODS: Since the efficacy of antihypertensive treatment among kidney transplant recipients is unknown, we analysed data on office-based blood pressure and use of antihypertensive drugs from the Netherlands Organ Transplant Registry on 5415 kidney transplant recipients. Additionally, we studied dosages, prevalence of treatment-resistant hypertension and 24-hour sodium excretion in 534 kidney transplant recipients from our centre to explore possibilities for therapy optimisation. RESULTS: In patients registered in the Netherlands Organ Transplant Registry, median blood pressure was 134/80 mmHg (interquartile range 122-145/70-85). In 77.2%, the blood pressure was ≥130/80 mmHg; of these patients 10.4% had no registered use, 30.0% used one and 25.9% used ≥3 classes of antihypertensive agents. Parameters from our centre were comparable: 78.7% had a median blood pressure of ≥130/80 mmHg of whom 14.5% had no registered use of antihypertensives and 26.4% used ≥3 classes. Sub-maximal dosages were prescribed in 74.0% of the kidney transplant recipients with a blood pressure of ≥130/80 mmHg while using at least one antihypertensive agent. Treatment-resistant hypertension was present in 7.7%. Median 24-hour sodium excretion was 147 mmol/day (interquartile range 109-195). CONCLUSIONS: This study suggests that therapeutic optimisation of antihypertensive treatment in kidney transplant recipients is, in theory, frequently possible by intensifying pharmacological treatment and by providing more advice on dietary sodium restrictions.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Transplante de Rim , Adulto , Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Resistência a Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Sistema de Registros , Sódio/urinaRESUMO
Kidney transplantation is the best treatment option for patients with end-stage renal failure. At present, approximately 800 Dutch patients are registered on the active waiting list of Eurotransplant. The waiting time in the Netherlands for a kidney from a deceased donor is on average between 3 and 4 years. During this period, patients are fully dependent on dialysis, which replaces only partly the renal function, whereas the quality of life is limited. Mortality among patients on the waiting list is high. In order to increase the number of kidney donors, several initiatives have been undertaken by the Dutch Kidney Foundation including national calls for donor registration and providing information on organ donation and kidney transplantation. The aim of the national PROCARE consortium is to develop improved matching algorithms that will lead to a prolonged survival of transplanted donor kidneys and a reduced HLA immunization. The latter will positively affect the waiting time for a retransplantation. The present algorithm for allocation is among others based on matching for HLA antigens, which were originally defined by antibodies using serological typing techniques. However, several studies suggest that this algorithm needs adaptation and that other immune parameters which are currently not included may assist in improving graft survival rates. We will employ a multicenter-based evaluation on 5429 patients transplanted between 1995 and 2005 in the Netherlands. The association between key clinical endpoints and selected laboratory defined parameters will be examined, including Luminex-defined HLA antibody specificities, T and B cell epitopes recognized on the mismatched HLA antigens, non-HLA antibodies, and also polymorphisms in complement and Fc receptors functionally associated with effector functions of anti-graft antibodies. From these data, key parameters determining the success of kidney transplantation will be identified which will lead to the identification of additional parameters to be included in future matching algorithms aiming to extend survival of transplanted kidneys and to diminish HLA immunization. Computer simulation studies will reveal the number of patients having a direct benefit from improved matching, the effect on shortening of the waiting list, and the decrease in waiting time.
Assuntos
Teste de Histocompatibilidade/métodos , Falência Renal Crônica/cirurgia , Transplante de Rim/mortalidade , Obtenção de Tecidos e Órgãos/métodos , Listas de Espera , Epitopos de Linfócito B/imunologia , Epitopos de Linfócito T/imunologia , Rejeição de Enxerto/imunologia , Sobrevivência de Enxerto/imunologia , Antígenos HLA/imunologia , Humanos , Rim/imunologia , Rim/cirurgia , Qualidade de Vida , Diálise RenalRESUMO
INTRODUCTION: Complications of the transplant ureter are the most important cause of surgical morbidity after renal transplantation. The presence of ureteral duplication in the renal graft might result in an increased complication rate. We analyzed our data of double-ureter renal transplantations using a case-control study design. Additionally, we performed a review of the literature. METHODS: From January 1995 to April 2012, 12 patients received a donor kidney with a double ureter (0.8%). We created a control group of 24 patients matched in age, sex, donor type, and ureteral stenting. Patient charts and surgical reports were reviewed retrospectively. RESULTS: In 7 patients both ureters were separately anastomosed to the bladder. In 4 patients a common ostium was created. In 1 patient 1 of the 2 ureters was ligated. No postoperative urologic complications occured. In the single-ureter group, the urologic complication rate was 17% (P = .71). Mean creatinine levels after transplantation were comparable between both groups. DISCUSSION: A double-ureter donor kidney is not associated with an increased complication rate after renal transplantation and yields equal outcomes as compared to single-ureter donor kidneys. We conclude that transplantation of a kidney with a duplicated ureter is safe.
Assuntos
Transplante de Rim , Ureter/anormalidades , Adulto , Anastomose Cirúrgica , Estudos de Casos e Controles , Creatinina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doadores de TecidosRESUMO
Polyomaviruses are able to drive malignant transformation in rodent models, and have been implicated in the aetiology of a variety of human malignancies. However, the reports on this association in humans are strongly conflicting. Here we describe a renal transplant (RT) recipient with ureteral stenosis against the background of polyomavirus BK (BKV) activity. Six and a half years after transplantation, this patient developed metastasised bladder cancer. Prior to the diagnosis of cancer, atypical cells were detected in the urine that were denoted as 'decoy cells': virally infected epithelial cells that are frequently seen in the urine of RT recipients with BKV (re)activation, which may morphologically resemble malignant cells. Intriguingly, the primary urothelial carcinoma, as well as the mesenterial and two intestinal metastases, stained positive with antibodies against polyomavirus virus large T antigen protein, whereas the adjacent healthy tissue did not. This case suggests a role for BKV in the pathogenesis of bladder cancer, at least in the context of immunodeficiency.
Assuntos
Vírus BK , Carcinoma de Células de Transição/virologia , Infecções por Polyomavirus , Infecções Tumorais por Vírus , Neoplasias da Bexiga Urinária/virologia , Humanos , Transplante de Rim , Masculino , Pessoa de Meia-IdadeRESUMO
In this study, we assessed the safety of the new organ preservation solution polysol solution in the clinical setting of living kidney transplantation. We conducted a prospective pilot study in nine adult donor-recipient couples using polysol solution for washout and cold storage of kidney grafts. Adverse reactions possibly related to the use of polysol solution as well as renal function at 1, 6, and 12 months after transplantation were monitored. All living kidney transplantation performed in adults in our center within 2002 to 2008 using the University of Winconsin solution served as controls (n = 190). The use of polysol solution was associated with a higher acute rejection rate compared to University of Wisconsin solution at all time points. Also, antibody-mediated rejection occurred more frequently in the polysol group. Renal function at all time points was also comparable between the groups. This pilot study in living kidney transplantation is the first clinical study on the use of polysol solution. Although the study was not powered on the endpoint rejection, we observed a high number of acute rejection and antibody-mediated rejection episodes in recipients of polysol solution preserved grafts as compared to University of Wisconsin solution controls. As a consequence the study was terminated prematurely.