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1.
Clin Transplant ; 38(4): e15298, 2024 04.
Artículo en Inglés | MEDLINE | ID: mdl-38545918

RESUMEN

BACKGROUND: Graft loss increases the risk of patient death after simultaneous pancreas-kidney (SPK) transplantation. The relative risk of each graft failure is complex due to the influence of several competing events. METHODS: This retrospective, single-center study compared 4-year patient survival according to the graft status using Kaplan-Meier (KM) and Competing Risk Analysis (CRA). Patient survival was also assessed according to five eras (Era 1: 2001-2003; Era 2: 2004-2006; Era 3: 2007-2009; Era 4: 2010-2012; Era 5: 2012-2015). RESULTS: Between 2000 and 2015, 432 SPK transplants were performed. Using KM, patient survival was 86.5% for patients without graft loss (n = 333), 93.4% for patients with pancreas graft loss (n = 46), 43.7% for patients with kidney graft loss (n = 16), and 25.4% for patients with pancreas and kidney graft loss (n = 37). Patient survival was underestimated using KM versus CRA methods in patients with pancreas and kidney graft losses (25.4% vs. 36.2%), respectively. Induction with lymphocyte depleting antibodies was associated with 81% reduced risk (HR.19, 95% CI.38-.98, p = .0048), while delayed kidney function (HR 2.94, 95% CI 1.09-7.95, p = .033) and surgical complications (HR 2.94, 95% CI 1.22-7.08, p = .016) were associated with higher risk of death. Four-year patient survival increased from Era 1 to Era 5 (79% vs. 87.9%, p = .047). CONCLUSION: In this cohort of patients, kidney graft loss, with or without pancreas graft loss, was associated with higher mortality after SPK transplantation. Compared to CRA, the KM model underestimated survival only among patients with pancreas and kidney graft losses. Patient survival increased over time.


Asunto(s)
Diabetes Mellitus Tipo 1 , Trasplante de Riñón , Trasplante de Páncreas , Humanos , Diabetes Mellitus Tipo 1/cirugía , Estudios Retrospectivos , Trasplante de Páncreas/métodos , Medición de Riesgo , Páncreas , Supervivencia de Injerto
2.
Transpl Infect Dis ; 26(1): e14204, 2024 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-38010722

RESUMEN

BACKGROUND: Because COVID-19 has been associated with high lethality rates among kidney transplant recipients (KTR), but also with a severe disruption and delays in overall healthcare, this study aims to evaluate the excess mortality in the pandemic era among KTR in a high-volume Brazilian transplant center. METHODS: This study used data from a single center that provides follow-up on all its transplant recipients. The population of interest included all the patients who were transplanted between August 31, 1983 and December 31, 2022 and who were live from January 1, 2014. Using the "AutoRegressive Integrated Moving Average" forecasting algorithm, the expected mortality for the pandemic era (2020-2022) was modeled from the pre-pandemic era (2014-2019). RESULTS: There were 12 077 KTRs at risk of dying in the entire observation period. In the pre-pandemic era, there were 21 deaths per 1000 patients at risk. In the pandemic era, there were 1429 observed deaths (rate of 47 deaths per 1000 patients at risk) versus the expected 587 deaths, resulting in an absolute number of 842 excess deaths, or an observed-to-expected ratio of 2.4, or an absolute rate of 26 deaths in excess per 1000 patients at risk. The excess deaths exhibited a temporal pattern mirroring that of the surges in new cases and lethality rates of COVID-19. COVID-19-related deaths drove 94% of excess mortality in the pandemic era. CONCLUSION: In this large cohort of KTR under centralized follow-up, more than twofold excess mortality was primarily driven by COVID-19-related deaths, highlighting the vulnerability of this population to the most severe presentation of SARS-CoV-2 infection.


Asunto(s)
COVID-19 , Trasplante de Riñón , Humanos , Receptores de Trasplantes , Trasplante de Riñón/efectos adversos , Pandemias , SARS-CoV-2 , Mortalidad
3.
Pediatr Transplant ; 28(3): e14713, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38553819

RESUMEN

BACKGROUND: This study aimed to compare the efficacy and safety of basiliximab (BAS) versus a single dose of anti-thymocyte globulin (r-ATG) induction therapy in pediatric kidney transplant recipients (KTRs). METHODS: This single-center retrospective comparative cohort study included all pediatric KTRs from May 2013 to April 2018 and followed up to 12 months. In the first period, all recipients received BAS, while from May 2016, a single 3 mg/kg dose of r-ATG was instituted. Maintenance therapy consisted of a calcineurin inhibitor plus prednisone plus azathioprine or mycophenolate. RESULTS: A total of 227 patients were included (BAS, n = 113; r-ATG, n = 114). The main combination of immunosuppressive drugs was tacrolimus, prednisone, and azathioprine in both groups (87% vs. 88%, p = .718). Patients receiving r-ATG showed superior survival-free of the composite endpoint (acute rejection, graft loss, or death; 76% vs. 61%, p = .003; HR 2.08, 1.29-3.34, p = .003) and lower incidence of biopsy-proven acute rejection (10% vs. 21%, p = .015). There was no difference in the overall incidence of CMV infection (33% vs. 37%, p = .457), PTLD (1% vs. 3%, p = .309), 30-day hospital readmissions (24% vs. 23%, p = .847), and kidney function at 12 months (86 ± 29 vs. 84 ± 30 mL/min/1.73m2, p = .614). CONCLUSIONS: These data suggest that induction therapy with a single 3 mg/kg dose of r-ATG is associated with higher efficacy for preventing acute rejection and similar safety profile compared to BAS.


Asunto(s)
Suero Antilinfocítico , Trasplante de Riñón , Humanos , Niño , Basiliximab/uso terapéutico , Suero Antilinfocítico/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Prednisona/uso terapéutico , Estudios Retrospectivos , Estudios de Cohortes , Azatioprina , Quimioterapia de Inducción , Rechazo de Injerto/prevención & control , Rechazo de Injerto/epidemiología , Inmunosupresores/uso terapéutico , Proteínas Recombinantes de Fusión/uso terapéutico , Receptores de Trasplantes
4.
Medicina (Kaunas) ; 59(9)2023 Aug 27.
Artículo en Inglés | MEDLINE | ID: mdl-37763674

RESUMEN

Background and Objectives: Overweight/obesity puts individuals at greater risk for COVID-19 progression and mortality. We aimed to evaluate the impact of overweight/obesity on oxygen (O2) requirement outcomes of male and female kidney transplant recipients (KTRs) during the COVID-19 pandemic. Materials and Methods: We conducted a retrospective analysis of a cohort of KTRs diagnosed with COVID-19. Participants were stratified based on BMI categories, and data on the need for O2 therapy outcome were collected and analyzed separately for male and female KTRs. Results: In total, 284 KTRs (97 males and 187 females) were included in the study. Overweight/obesity was observed in 60.6% of male KTRs and 71% of female KTRs. Strikingly, overweight/obese women had a significantly higher requirement for supplemental O2 (63.3% vs. 41.7%, OR = 2.45, p = 0.03), particularly among older individuals (OR = 1.05, p = 0.04), smokers (OR = 4.55, p = 0.03), those with elevated lactate dehydrogenase (LDH) levels (OR = 1.01, p = 0.006), and those with lower admission and basal estimated glomerular filtration rate (eGFR) levels. Within this cohort, the necessity for O2 supplementation was correlated with more unfavorable outcomes. These included heightened mortality rates, transfers to the intensive care unit, employment of invasive mechanical ventilation, and the emergence of acute kidney injury requiring hemodialysis. On the other hand, although overweight/obese male KTRs had a higher prevalence of hypertension and higher fasting blood glucose levels, no significant association was found with COVID-19-related outcomes when compared to lean male KTRs. Conclusions: Overweight/obesity is highly prevalent in KTRs, and overweight/obese women demonstrated a higher need for supplemental O2. Therefore, the early identification of factors that predict a worse outcome in overweight/obese female KTRs affected by COVID-19 contributes to risk stratification and guides therapeutic decisions.


Asunto(s)
COVID-19 , Trasplante de Riñón , Femenino , Masculino , Humanos , Sobrepeso/complicaciones , Sobrepeso/epidemiología , Caracteres Sexuales , Pandemias , Estudios Retrospectivos , COVID-19/epidemiología , Obesidad/complicaciones , Obesidad/epidemiología , Oxígeno
5.
Am J Transplant ; 22(2): 610-625, 2022 02.
Artículo en Inglés | MEDLINE | ID: mdl-34416075

RESUMEN

This analysis, using data from the Brazilian kidney transplant (KT) COVID-19 study, seeks to develop a prediction score to assist in COVID-19 risk stratification in KT recipients. In this study, 1379 patients (35 sites) were enrolled, and a machine learning approach was used to fit models in a derivation cohort. A reduced Elastic Net model was selected, and the accuracy to predict the 28-day fatality after the COVID-19 diagnosis, assessed by the area under the ROC curve (AUC-ROC), was confirmed in a validation cohort. The better calibration values were used to build the applicable ImAgeS score. The 28-day fatality rate was 17% (n = 235), which was associated with increasing age, hypertension and cardiovascular disease, higher body mass index, dyspnea, and use of mycophenolate acid or azathioprine. Higher kidney graft function, longer time of symptoms until COVID-19 diagnosis, presence of anosmia or coryza, and use of mTOR inhibitor were associated with reduced risk of death. The coefficients of the best model were used to build the predictive score, which achieved an AUC-ROC of 0.767 (95% CI 0.698-0.834) in the validation cohort. In conclusion, the easily applicable predictive model could assist health care practitioners in identifying non-hospitalized kidney transplant patients that may require more intensive monitoring. Trial registration: ClinicalTrials.gov NCT04494776.


Asunto(s)
COVID-19 , Trasplante de Riñón , Prueba de COVID-19 , Humanos , Internet , Trasplante de Riñón/efectos adversos , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , SARS-CoV-2 , Receptores de Trasplantes
6.
Transpl Int ; 35: 10375, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35957939

RESUMEN

Kidney transplant recipients present higher rates of pre-existing comorbidities, in particular diabetes mellitus (DM), hypertension, and cardiac disease. We aimed to verify the main risk factors related to DM that contribute to COVID-19 progression and mortality in a kidney transplant setting. From March to August 2020, we evaluated 300 kidney transplant recipients affected by COVID-19. We used propensity score matching (PSM) to estimate the impact of DM on COVID-19. After matching, all baseline characteristics were well balanced between those with and without DM (n = 100 in each group). Case fatality rate, the requirement of invasive mechanical ventilation (IMV), and acute kidney injury (AKI) were associated with previous fasting blood glucose, and C-reactive protein (CRP), and lactate dehydrogenase (LDH) levels on admission. These findings were similar in kidney transplant patients with and without DM. Glycemia on admission and estimated glomerular filtration rate (eGFR) either on admission or basal correlated to the need of IMV and development of AKI, respectively. Poor glycaemic control, eGFR, markers of inflammation (CRP) and tissue damage (LDH) were indicative of COVID-19 burden in kidney transplant recipients and may be useful tools for risk-stratifying this population, independently of the DM status, during the pandemic.


Asunto(s)
Lesión Renal Aguda , COVID-19 , Diabetes Mellitus , Trasplante de Riñón , Lesión Renal Aguda/etiología , Diabetes Mellitus/epidemiología , Diabetes Mellitus/etiología , Humanos , Trasplante de Riñón/efectos adversos , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Receptores de Trasplantes
7.
Transpl Int ; 35: 10205, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35185380

RESUMEN

Data from the general population suggest that fatality rates declined during the course of the pandemic. This analysis, using data extracted from the Brazilian Kidney Transplant COVID-19 Registry, seeks to determine fatality rates over time since the index case on March 3rd, 2020. Data from hospitalized patients with RT-PCR positive SARS-CoV-2 infection from March to August 2020 (35 sites, 878 patients) were compared using trend tests according to quartiles (Q1: <72 days; Q2: 72-104 days; Q3: 105-140 days; Q4: >140 days after the index case). The 28-day fatality decreased from 29.5% (Q1) to 18.8% (Q4) (pfor-trend = 0.004). In multivariable analysis, patients diagnosed in Q4 showed a 35% reduced risk of death. The trend of reducing fatality was associated with a lower number of comorbidities (20.7-10.6%, p for-trend = 0.002), younger age (55-53 years, pfor-trend = 0.062), and better baseline renal function (43.6-47.7 ml/min/1.73 m2, pfor-trend = 0.060), and were confirmed by multivariable analysis. The proportion of patients presenting dyspnea (pfor-trend = 0.001) and hypoxemia (pfor-trend < 0.001) at diagnosis, and requiring intensive care was also found reduced (pfor-trend = 0.038). Despite possible confounding variables and time-dependent sampling differences, we conclude that COVID-19-associated fatality decreased over time. Differences in demographics, clinical presentation, and treatment options might be involved.


Asunto(s)
COVID-19 , Trasplante de Riñón , Estudios de Cohortes , Humanos , Trasplante de Riñón/efectos adversos , Sistema de Registros , SARS-CoV-2 , Receptores de Trasplantes
8.
Int J Paediatr Dent ; 32(6): 894-902, 2022 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-35316550

RESUMEN

BACKGROUND: Children and adolescents undergoing kidney transplantation may present oral conditions after the procedure, but a few studies have recently described them. AIM: To describe the oral conditions of post-renal transplant children and adolescents. DESIGN: Two calibrated dentists examined all the participants by assessing caries experience, enamel defects, periodontal condition and soft tissue lesions. RESULTS: A total of 120 participants were included in the study, in which 63 (52.5%) were male and 57 (47.5%) were female, with a mean age of 12.78 ± 3.9 years. Among the participants, 104 (86.7%) showed at least one oral change directly related to kidney disease. The most frequent oral findings were enamel defect (49/120; 40.8%) and drug-induced gingival overgrowth (DIGO) (20/120; 16.7%). Gingival bleeding was observed on probing in 115 (95.8%) participants, whereas 69 (57.5%) presented dental calculus and 51 (42.5%) had caries experience. CONCLUSION: Gingival bleeding, enamel defects and DIGO were the most frequent oral findings in kidney transplant children and adolescents. The use of amlodipine and anticonvulsants was associated with DIGO, and there was a positive correlation between oral ulcers and use of everolimus.


Asunto(s)
Caries Dental , Sobrecrecimiento Gingival , Trasplante de Riñón , Enfermedades Dentales , Adolescente , Amlodipino/efectos adversos , Anticonvulsivantes/efectos adversos , Niño , Everolimus/efectos adversos , Femenino , Sobrecrecimiento Gingival/inducido químicamente , Sobrecrecimiento Gingival/patología , Humanos , Trasplante de Riñón/efectos adversos , Masculino , Salud Bucal
9.
Transpl Int ; 34(2): 339-352, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33314321

RESUMEN

Induction therapy with rabbit anti-thymocyte globulin (rATG) in low-risk kidney transplant recipients (KTR) remains controversial, given the associated increased risk of cytomegalovirus (CMV) infection. This natural experiment compared 12-month clinical outcomes in low-risk KTR without CMV prophylaxis (January/3/13-September/16/15) receiving no induction or a single 3 mg/kg dose of rATG. We used logistic regression to characterize delayed graft function (DGF), negative binomial to characterize length of hospital stay (LOS), and Cox regression to characterize acute rejection (AR), CMV infection, graft loss, death, and hospital readmissions. Recipients receiving 3 mg/kg rATG had an 81% lower risk of AR (aHR 0.14 0.190.25 , P < 0.001) but no increased rate of hospital readmissions because of infections (0.68 0.911.21 , P = 0.5). There was no association between 3 mg/kg rATG and CMV infection/disease (aHR 0.86 1.101.40 , P = 0.5), even when the analysis was stratified according to recipient CMV serostatus positive (aHR 0.94 1.251.65 , P = 0.1) and negative (aHR 0.28 0.571.16 , P = 0.1). There was no association between 3 mg/kg rATG and mortality (aHR 0.51 1.253.08 , P = 0.6), and graft loss (aHR 0.34 0.731.55 , P = 0.4). Among low-risk KTR receiving no CMV pharmacological prophylaxis, 3 mg/kg rATG induction was associated with a significant reduction in the incidence of AR without an increased risk of CMV infection, regardless of recipient pretransplant CMV serostatus.


Asunto(s)
Infecciones por Citomegalovirus , Trasplante de Riñón , Suero Antilinfocítico , Citomegalovirus , Infecciones por Citomegalovirus/epidemiología , Rechazo de Injerto/prevención & control , Humanos , Inmunosupresores , Incidencia , Trasplante de Riñón/efectos adversos , Estudios Retrospectivos , Receptores de Trasplantes
10.
Transpl Infect Dis ; 23(5): e13706, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34322975

RESUMEN

BACKGROUND: Kidney transplant recipients have higher COVID-19 associated mortality compared to the general population. However, as only symptomatic patients seek medical attention, the current level of exposure, the main sources of acquisition, and the behavior of humoral immunity over time are poorly understood. METHODS: This cross-sectional prospective single-center study recruited kidney transplant recipients of any age living in Sao Paulo. A sample size of 401 patients was calculated considering the 17.2% seroprevalence in the municipality population from a published survey, a 95% confidence interval and an absolute error of 2%. RESULTS: Of the 2636 eligible patients, 416 were included. The seroprevalence for IgG anti-SARS-CoV-2 was 8.2%. Seroconversion rate decreased with increasing age, from 15.7% (18-35 years) to 8.3% (36-60 years) and 4.2% (>60 years, p = 0.042). Seropositivity among previously confirmed COVID-19 patients was 68.4%, followed by 9.4% in those with flu-like symptoms and only 4.6% among asymptomatic patients (p < 0.0001). Seroprevalence was significantly higher among patients reporting household contact (p = 0.018). Twenty-seven from the 34 IgG+ patients had a second test after 59 (IQR 50-63) days, and, in 33%, the IgG index became below the positivity threshold. CONCLUSIONS: In this cohort of kidney transplant recipients, the seroprevalence for IgG anti-SARS-CoV-2 was lower than that of the general population, decreased with ageing, and was associated with household contacts. In a considerable proportion of the patients, there was a significant decay in the IgG levels in a short period of time. Therefore, preventive strategies, such as prioritization for vaccination, should be urgently considered.


Asunto(s)
COVID-19 , Trasplante de Riñón , Adolescente , Adulto , Anticuerpos Antivirales , Brasil/epidemiología , Estudios Transversales , Humanos , Trasplante de Riñón/efectos adversos , Estudios Prospectivos , SARS-CoV-2 , Estudios Seroepidemiológicos , Receptores de Trasplantes , Adulto Joven
11.
Transpl Infect Dis ; 23(4): e13600, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-33728731

RESUMEN

INTRODUCTION: Hospital do Rim is a high-volume kidney transplant (KT) center located in São Paulo, a city with 12.2 million inhabitants. Over the last 18 years, we performed 11 436 KT, 70% of which from deceased donors. To mitigate the effects of reduction in the number of transplants on the waiting list, sequential measures were implemented when COVID-19 was declared pandemic. METHODS: The first step was to provide SARS-COV-2 RT-PCR testing for all symptomatic employees and patients and the compulsory use of personal protective equipment in the hospital facilities. Living donor KT were postponed, and all deceased donors and recipients were tested before the transplantation. The immunosuppressive protocols were maintained, and telehealth strategies were developed. RESULTS: Among the 1013 employees, there were 214 cases of COVID-19, nine required ward hospitalization, and no deaths occurred. In 26%, the probable source of contamination was occupational. From the first patient diagnosed with COVID-19 in 03/20/2020 till 10/21/2020, 523 deceased KT were performed, a 21% increase compared with 2019, with no confirmed donor-derived SARS-CoV-2 infection. Four patients were transplanted with a positive pretransplant SARS-CoV-2 test, but none of them developed the disease. Overall, of 11 875 KT followed in our center, 674 developed COVID-19. Among the hospitalized, 53% required mechanical ventilation, and 45% required hemodialysis. Their overall mortality rate was 27.5%. CONCLUSION: This experience shows the challenges that transplant centers faced as the pandemic unfolded and illustrates the effectiveness of the sequential measures implemented to provide a safe environment for transplantation.


Asunto(s)
COVID-19 , Trasplante de Riñón , Brasil , Humanos , Trasplante de Riñón/efectos adversos , Pandemias , SARS-CoV-2
12.
Emerg Infect Dis ; 26(6): 1329-1331, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32441623

RESUMEN

We describe cases of donor-derived transmission of Cryptococcus deuterogattii in 2 kidney transplant recipients in Brazil and published information on other cases. Prompt reduction of immunosuppression and initiation of antifungal therapy was required to successfully control the fungal infections and preserve engraftment.


Asunto(s)
Criptococosis , Cryptococcus gattii , Cryptococcus neoformans , Trasplante de Riñón , Antifúngicos/uso terapéutico , Brasil , Criptococosis/diagnóstico , Criptococosis/tratamiento farmacológico , Cryptococcus gattii/genética , Humanos , Trasplante de Riñón/efectos adversos , Receptores de Trasplantes
13.
Transpl Infect Dis ; 22(4): e13330, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32418331

RESUMEN

BACKGROUND: The objective was to assess the oral shedding and viremia of human herpesviruses in renal transplant recipients. METHODS: This is a cohort study in which the participants were examined in three different periods: the first within 24 hours before renal transplantation and the second and third ones 15-20 and 45-60 days after the transplantation. Mouthwash and blood samples were collected in each period and then submitted to screening for the presence of eight types of human herpesviruses by using multiplex PCR. RESULTS: HSV-1 and EBV were more frequent in the saliva after renal transplantation, 15- to 20-day period after the transplant. EBV was found in the saliva of 26 (35.6%) patients before renal transplantation and in 56.2% and 46.6% of them, in the 15- to 20-day and 45- to 60-day periods after the transplant, respectively. High detection rates (75.3%-78.1%) were found for HHV-7 despite the lack of significant variations between the study periods. There was no concordance between herpesviruses oral shedding and viremia. CONCLUSION: We concluded that the pattern of excretion of HSV-1 and EBV in saliva is changed immediately after renal transplantation, increasing in the 15- to 20-day period after the transplant surgery. No concordance between herpesviruses oral shedding and viremia was observed.


Asunto(s)
Infecciones por Herpesviridae/diagnóstico , Trasplante de Riñón/efectos adversos , Boca/virología , Receptores de Trasplantes/estadística & datos numéricos , Viremia , Esparcimiento de Virus , Adulto , Estudios de Cohortes , Citomegalovirus/aislamiento & purificación , Infecciones por Citomegalovirus/diagnóstico , Infecciones por Citomegalovirus/virología , Femenino , Herpesviridae/aislamiento & purificación , Herpesvirus Humano 1/aislamiento & purificación , Herpesvirus Humano 4/aislamiento & purificación , Herpesvirus Humano 7/aislamiento & purificación , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Saliva/virología , Carga Viral
14.
Acta Odontol Scand ; 78(3): 217-222, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-31718409

RESUMEN

Objective: To identify the oral lesions of individuals with kidney disease immediately before and shortly after kidney transplantation, taking into account the immunosuppressive regimen, antiviral prophylaxis and type of transplantation.Methods: A prospective observational cohort study was carried from January 2017 to January 2018. Eighty individuals aged 18 years or older who were admitted for kidney transplantation were eligible to participate. Clinical data regarding medical history, immunosuppressive therapy, antiviral prophylaxis, laboratorial data and oral examination were performed by the same trained researcher, in three different moments: 24 hours before transplantation (1st time point), 15-20 days (2nd time point) and 45-60 days (3rd time point) after transplantation.Results: In the first, second and third time points, it was found that 3.7% (3/80), 23.7% (18/76) and 25.7% (19/74) of the participants showed oral soft tissue lesions. Ulcers and candidiasis were the most frequent oral lesions, and they were associated with the use of everolimus (p = .005) and azathioprine (p = .034), respectively. Less patients reported xerostomia after transplantation than before (p < .001).Conclusions: Oral lesions are common in the short term after renal transplantation and are particularly related to both toxicities of immunosuppressive drugs and immunosuppression.


Asunto(s)
Huésped Inmunocomprometido , Inmunosupresores/efectos adversos , Trasplante de Riñón/efectos adversos , Enfermedades de la Boca/epidemiología , Enfermedades de la Boca/etiología , Adolescente , Adulto , Aloinjertos , Brasil/epidemiología , Estudios de Cohortes , Humanos , Inmunosupresores/administración & dosificación , Persona de Mediana Edad , Enfermedades de la Boca/inmunología , Complicaciones Posoperatorias , Estudios Prospectivos , Trasplante Homólogo
15.
Am J Transplant ; 19(5): 1421-1431, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-30556285

RESUMEN

Tuberculosis (TB) mortality is high among kidney transplant (KT) recipients. Although local epidemiology is an important factor, diagnostic/therapeutic challenges and immunosuppressive therapy (ISS) may influence outcomes. We analyzed the cumulative incidence (CumI) of TB in KT recipients receiving a variety of ISS with long-term follow-up. Our retrospective single-center cohort study included all KT procedures performed between January 1, 1998, and August 31, 2014, with follow-up until August 31, 2014. Induction therapy was based on perceived immunological risk; maintenance ISS included prednisone and calcineurin inhibitor (CNI) plus azathioprine (AZA), and mycophenolic acid (MPA) or mechanistic target of rapamycin inhibitor (mTORi). Thirty-four patients received belatacept/MPA. KT was performed on 11 453 patients and followed for 1989 (IQR 932 to 3632) days. Among these, 152 patients were diagnosed with TB (CumI 1.32%). Median time from KT to TB was 18.8 (IQR 7.2 to 60) months, with 59% of patients diagnosed after the first year. Unadjusted analysis revealed an increasing confidence interval (CI) of TB (0.94% CNI/AZA vs 1.6% CNI/MPA [HR = 1.62, 95% CI = 1.13 to 2.34, P = .009] vs 2.85% CNI/mTORi [HR = 2.45, 95% CI = 1.49 to 4.32, P < .001] vs 14.7% belatacept/MPA [HR = 13.14, 95% CI = 5.27 to 32.79, P < .001]). Thirty-seven (24%) patients died, and 39 (25.6%) patients experienced graft loss. Cytomegalovirus infection (P = .02) and definitive ISS discontinuation (P < .001) were associated with death. Rejection (P = .018) and ISS discontinuation (P = .005) occurred with graft loss. TB occurred at any time after KT and was influenced by ISS.


Asunto(s)
Inmunosupresores/administración & dosificación , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Tuberculosis/complicaciones , Tuberculosis/mortalidad , Abatacept/administración & dosificación , Adulto , Azatioprina/administración & dosificación , Inhibidores de la Calcineurina/administración & dosificación , Infecciones por Citomegalovirus/complicaciones , Femenino , Estudios de Seguimiento , Rechazo de Injerto , Humanos , Fallo Renal Crónico/epidemiología , Masculino , Persona de Mediana Edad , Ácido Micofenólico/administración & dosificación , Estudios Retrospectivos , Riesgo , Serina-Treonina Quinasas TOR/antagonistas & inhibidores , Resultado del Tratamiento
16.
Clin Transplant ; 33(3): e13467, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30580452

RESUMEN

Early hospital readmission (EHR) is associated with increased mortality after kidney transplantation. This is influenced by population demographics and the comprehensiveness of the healthcare system. We investigated the incidence and risk factors associated with EHR and 1-year patient and graft survivals. METHODS: We included all recipients of kidney transplant between 2011 and 2012. We excluded recipients younger than 18 years, retransplants and who died or lost the graft during the index hospital admission. RESULTS: Among 1175 recipients, the incidence of EHR was 26.6%. The main reasons for EHR were infection (67%), surgical complications (14%), and metabolic disturbances (11%). Independent risk factors associated with EHR were recipient age (OR = 1.95, 95% CI 1.46-2.63, P < 0.001), CMV serology negative (OR = 2.2, 95% CI 1.31-3.65, P = 0.003), use of rabbit anti-thymocyte globulin (OR = 2.06, 95% CI 1.33-3.13, P < 0.001), treatment for acute rejection during index hospitalization (OR = 1.68, 95% CI 1.15-2.47, P = 0.008), and length of stay (OR = 1.72, 95% CI 1.18-2.5, P = 0.005). Patient (88.8% vs 97.6%, P < 0.001) and death-censored graft (97.4% vs 99.0%, P < 0.001) survivals were inferior comparing patients with and without EHR. Conclusion EHR was independently associated with mortality (OR 4.01, 95% CI 2.13-7.54, P < 0.001), but its incidence and causes are directly related to the local characteristics of the population and healthcare system.


Asunto(s)
Rechazo de Injerto/diagnóstico , Hospitalización/estadística & datos numéricos , Fallo Renal Crónico/cirugía , Trasplante de Riñón/mortalidad , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias , Práctica de Salud Pública/estadística & datos numéricos , Adulto , Femenino , Estudios de Seguimiento , Rechazo de Injerto/etiología , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia
17.
Clin Transplant ; 33(10): e13689, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31400155

RESUMEN

OBJECTIVES: To describe the incidence of cytomegalovirus (CMV) infection/disease in kidney transplant recipients receiving an mTOR-inhibitor-containing immunosuppressive regimen without prophylactic CMV treatment. METHODS: This single-center retrospective cohort analysis included all de novo kidney transplant recipients (09/15/2015-07/31/2017) receiving 3 mg/kg single dose of rabbit antithymocyte globulin induction, tacrolimus, everolimus, and prednisone. Preemptive therapy was initiated only in patients deemed at higher risk for CMV infection: (a) D+/R- CMV patients; (b) after treatment for acute rejection (ARt); and (c) after everolimus discontinuation (EVRd). RESULTS: Of 230 patients, there were no episodes of CMV disease among 217 (94%) without criteria to initiate preemptive therapy. Of 77 (33.5%) patients initiating preemptive therapy, 13 were D+/R-, 30 were ARt, and 34 were EVRd. The overall incidence of first CMV infection/disease was 6% (46.1% in D+/R-, 13.3% ARt [all patients had also discontinued everolimus], and 11.8% after early [<90 days] EVRd). The incidence of biopsy-proven acute rejection was 5.6%, and median glomerular filtration rate at month 12 was 47 mL/min/1.73m2 . One-year patient and death-censored graft survivals were 97.4% and 98.1%. CONCLUSION: This study suggests that everolimus-containing immunosuppressive regimen reduces the need for preventive strategies for CMV infection in the majority of kidney transplant recipients, reducing antiviral drug-associated toxicities and healthcare-related expenditures.


Asunto(s)
Infecciones por Citomegalovirus/tratamiento farmacológico , Citomegalovirus/aislamiento & purificación , Rechazo de Injerto/tratamiento farmacológico , Supervivencia de Injerto/efectos de los fármacos , Inmunosupresores/administración & dosificación , Trasplante de Riñón/efectos adversos , Serina-Treonina Quinasas TOR/antagonistas & inhibidores , Adulto , Suero Antilinfocítico/administración & dosificación , Brasil/epidemiología , Infecciones por Citomegalovirus/epidemiología , Infecciones por Citomegalovirus/microbiología , Everolimus/administración & dosificación , Femenino , Estudios de Seguimiento , Rechazo de Injerto/diagnóstico , Rechazo de Injerto/etiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Prednisona/administración & dosificación , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tacrolimus/administración & dosificación
18.
Transpl Int ; 32(11): 1127-1143, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31278785

RESUMEN

The optimal immunosuppressive regimen for recipients of expanded criteria donor (ECD) kidneys has not been identified. In this single-center study, 171 recipients of ECD kidney transplants were randomized to receive antithymocyte globulin induction, and delayed introduction of reduced dose tacrolimus, prednisone and everolimus (r-ATG/EVR, n = 88), or mycophenolate (r-ATG/MPS, n = 83). No cytomegalovirus (CMV) pharmacological prophylaxis was used. The primary endpoint was the incidence of CMV infection/disease at 12 months. Secondary endpoints included treatment failure [first biopsy-proven acute rejection (BPAR), graft loss, or death] and safety. Patients treated with EVR showed a 89% risk reduction (13.6 vs. 71.6%; HR 0.11, 95% CI 0.06-0.220, P < 0.001) in the incidence of first CMV infection/disease. Incidences of BPAR (16% vs. 5%, P = 0.021), graft loss (11% vs. 1%, P = 0.008), death (10% vs. 1%, P = 0.013), and treatment discontinuation (40% vs. 28%, P = 0.12) were higher in the r-ATG/EVR, leading to premature study termination. Mean glomerular filtration rate was lower in r-ATG/EVR (31.8 ± 18.8 vs. 42.6 ± 14.9, P < 0.001). In recipients of ECD kidney transplants receiving no CMV pharmacological prophylaxis, the use of everolimus was associated with higher treatment failure compared with mycophenolate despite the significant reduction in the incidence of CMV infection/disease (ClinicalTrials.gov.NCT01895049).


Asunto(s)
Suero Antilinfocítico/administración & dosificación , Selección de Donante/métodos , Everolimus/administración & dosificación , Fallo Renal Crónico/cirugía , Trasplante de Riñón/métodos , Ácido Micofenólico/administración & dosificación , Anciano , Infecciones por Citomegalovirus/prevención & control , Funcionamiento Retardado del Injerto , Selección de Donante/normas , Femenino , Tasa de Filtración Glomerular , Rechazo de Injerto , Humanos , Terapia de Inmunosupresión , Inmunosupresores/uso terapéutico , Incidencia , Riñón/cirugía , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Prednisona/administración & dosificación , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Tacrolimus/administración & dosificación , Resultado del Tratamiento
19.
Transpl Infect Dis ; 21(6): e13106, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31081566

RESUMEN

INTRODUCTION: The complex interaction between cytomegalovirus (CMV) infection and acute rejection after kidney transplantation is well recognized. METHODS: This single center retrospective cohort analysis investigated the incidence and risk factors associated with CMV infection after treatment for acute rejection (tAR) in kidney transplant recipients receiving only CMV preemptive therapy. Of the 938 kidney transplants performed between 04/30/2014 and 04/30/2015 we identified 87 (9.3%) that were treated for acute rejection within the first year. RESULTS: Most patients (64%) received rATG induction therapy followed by tacrolimus in combination with azathioprine (67%) or mycophenolate (33%) and corticosteroids. The incidence of CMV infection/disease after tAR was 47%, of which 73% occurred within 30 days. Using multivariable logistic regression analysis, eGFR at 1 month (OR = 0.98; 95% CI, 0.97-0.99; P = 0.007) and timing of tAR (OR = 0.98; 95% CI, 0.96-0.99; P = 0.021) were independently associated with CMV infection/disease after tAR. CONCLUSION: In this cohort of kidney transplant recipients receiving tacrolimus-based immunosuppressive and preemptive CMV therapy, almost 50% developed CMV infection/disease after tARin the first year of transplantation. Early rejection and poor initial renal function were risk factors associated with CMV infection or disease.


Asunto(s)
Infecciones por Citomegalovirus/epidemiología , Citomegalovirus/inmunología , Rechazo de Injerto/tratamiento farmacológico , Inmunosupresores/efectos adversos , Trasplante de Riñón/efectos adversos , Adulto , Anciano , Aloinjertos/efectos de los fármacos , Aloinjertos/inmunología , Aloinjertos/fisiopatología , Profilaxis Antibiótica/métodos , Suero Antilinfocítico/administración & dosificación , Suero Antilinfocítico/efectos adversos , Antivirales/uso terapéutico , Azatioprina/administración & dosificación , Azatioprina/efectos adversos , Citomegalovirus/aislamiento & purificación , Infecciones por Citomegalovirus/inmunología , Infecciones por Citomegalovirus/virología , Quimioterapia Combinada/métodos , Femenino , Tasa de Filtración Glomerular/efectos de los fármacos , Tasa de Filtración Glomerular/fisiología , Rechazo de Injerto/inmunología , Humanos , Inmunosupresores/administración & dosificación , Incidencia , Riñón/efectos de los fármacos , Riñón/inmunología , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Ácido Micofenólico/administración & dosificación , Ácido Micofenólico/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Tacrolimus/administración & dosificación , Tacrolimus/efectos adversos , Adulto Joven
20.
Nephrology (Carlton) ; 24(11): 1179-1188, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-30891898

RESUMEN

AIM: Focal segmental glomerulosclerosis recurs in up to 30% and up to 80% of adult and pediatric kidney transplant recipients, respectively. There is no standard of care treatment. The purpose of this study was to evaluate clinical characteristics, treatments and outcomes of patients with focal segmental glomerulosclerosis recurrence (FSGSr). METHODS: This was a retrospective single-center cohort study including FSGSr patients treated with plasmapheresis (PP) and combinations of high dose steroids, cyclosporine and rituximab. RESULTS: Among 61 patients included in this analysis the median time to diagnosis was 19 days. The incidence of first biopsy-confirmed FSGSr was 18% reaching 52.4% with follow-up biopsies. During PP treatment 54% of the patients developed infectious complications. PP was discontinued in 37% of patients due to treatment failure (no remission or graft loss) and in 26% due to an adverse event. All patients who discontinued PP due to adverse event did not show clinical response or lost the allograft. The incidence of acute rejection was 34.4%. The incidences of partial and complete remissions were 16.4% and 27.8%, respectively. Overall 6-years patient and graft survivals were 90.7% and 64.5%, respectively. CONCLUSION: This analysis confirms the low, variable and unpredictable rate of FSGSr remission, inconsistencies among available therapeutic options and its high rate of adverse events, and the negative impact on graft survival.


Asunto(s)
Glomeruloesclerosis Focal y Segmentaria/epidemiología , Trasplante de Riñón , Adolescente , Adulto , Niño , Femenino , Glomeruloesclerosis Focal y Segmentaria/terapia , Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Humanos , Trasplante de Riñón/efectos adversos , Masculino , Persona de Mediana Edad , Plasmaféresis/efectos adversos , Recurrencia , Estudios Retrospectivos , Adulto Joven
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