Adolescencia, adherencia y transición: Experiencia de un centro de trasplante renal pediátrico / Adolescence, adherence, and transition: Experience from a pediatric renal transplant center

Con el advenimiento de nuevas técnicas quirúrgicas y medicaciones inmunosupresoras la sobrevida de los niños trasplantados mejoró, llegando a la adultez. La continuidad de su tratamiento requiere un proceso planificado que permita su tránsito a un sistema de salud orientado al adulto. El objeto de este trabajo es mostrar la transición a centros de adultos en una cohorte de pacientes trasplantados renales en el Hospital Garrahan, describir sus características clínicas y demográficas, su evolución, y oportunidades de mejora implementadas. Debido a cambios médicos y su abordaje desde la interdisciplina, se dividió a la población en tres periodos: era 1 (1988-1999), era 2 (2000-2009), y era 3 (2010- 2023). En la era 1, 179 adolescentes continuaron su atención médica en un centro de adultos, 212 en la era 2 y 201 en la era 3. En la era 1 el seguimiento estaba coordinado por el nefrólogo de cabecera y eran consultados los servicios de Urología, Servicio Social y Salud Mental. En la era 2, se fortaleció el trabajo en interdisciplina y aún más a partir del 2011. Surgieron centros de trasplante de adultos que recibían adolescentes y médicos dedicados a ellos en forma preferencial. En la actualidad la transición comienza a los 12 años y progresa hasta los 18. El modelo implementado es la transición directa, entre el nefrólogo pediatra y el de adultos, con varias consultas secuenciales en ambos centros. Si bien la sobrevida del paciente e injerto mejoraron, el rechazo, asociado a no adherencia, es una asignatura por mejorar (AU)

With the advent of new surgical techniques and immunosuppressive medications, the survival of transplanted children has improved, allowing them to reach adulthood. The continuity of their treatment requires a planned process that facilitates their transition to an adult-oriented healthcare system. The aim of this study was to examine the transition to adult centers in a cohort of renal transplant patients at Garrahan Hospital, describing their clinical and demographic characteristics, their evolution, and the improvement opportunities implemented. Based on medical changes and the interdisciplinary approach, the population was divided into three periods: era 1 (1988- 1999), era 2 (2000-2009), and era 3 (2010-2023). In era 1, 179 adolescents continued their medical care in an adult center, 212 in era 2, and 201 in era 3. In era 1, follow-up was coordinated by the attending nephrologist with consultations from Urology, Social Services, and Mental Health Services. In era 2, interdisciplinary work was strengthened, and even more so since 2011. Adult transplant centers were created to receive adolescents with physicians dedicated to their care on a preferential basis. Currently, the transition begins at 12 years of age and progresses up to 18. The implemented model involves direct transition between the pediatric nephrologist and the adult nephrologist, with several sequential consultations in both centers. Although patient and graft survival have improved, rejection associated with non-adherence remains an area for improvement

Comparison of Anatomically of Medial Plantar Flap versus Reverse Sural Fasciocutaneous Flap in the Treatment of Skin Defects After Cutaneous Squamous Cell Carcinoma Excision

SUMMARY: To compare the advantages and disadvantages of reverse sural fasciocutaneous flap (RSFF) versus medial plantar flap (MPF) in the treatment of skin defects after excision of squamous cell carcinoma (SCC) of the heel. The research participants were 80 SCC patients admitted to Lishui People's Hospital between January 2019 and April 2022, who were assigned to RSFF group (n=37) and MPF group (n=43) according to the flap type. After a one-year follow-up, the survival, flap necrosis and ulceration, as well as pain and tactile sensation recovery of both groups were counted. At the last follow-up, the clinical response was evaluated, and Short-Form 36 Item Health Survey (SF-36) and appearance satisfaction surveys were conducted. No patients died in either group, and one patient in each group developed flap necrosis. The MPF group had better sensory recovery and a lower incidence of flap ulceration (P0.05). The cosmetic satisfaction was higher in MPF group than in RSFF group (P<0.05). MPF contributes to beautiful appearance, better sensory recovery, and low risk of long-term ulceration, while RSFF is suitable for lesions with large defects or those located at the lateral heel.

El objetivo del estudio fue comparar las ventajas y desventajas del colgajo fasciocutáneo sural inverso (RSFF) versus el colgajo plantar medial (MPF) en el tratamiento de defectos de la piel después de la escisión de un carcinoma de células escamosas (CCE) del talón. Los participantes de la investigación fueron 80 pacientes con CCE ingresados en el Hospital Popular de Lishui entre enero de 2019 y abril de 2022, que fueron asignados al grupo RSFF (n=37) y al grupo MPF (n=43) según el tipo de colgajo. Después de un año de seguimiento, se observó la supervivencia, la necrosis y ulceración del colgajo, así como la recuperación del dolor y la sensación táctil de ambos grupos. En el último seguimiento, se evaluó la respuesta clínica y se realizaron encuestas de salud de formato corto de 36 ítems (SF-36) y encuestas de satisfacción. Ningún paciente falleció en ninguno de los grupos y un paciente de cada grupo desarrolló necrosis del colgajo. El grupo MPF tuvo una mejor recuperación sensorial y una menor incidencia de ulceración del colgajo (P 0,05). La satisfacción cosmética fue mayor en el grupo MPF que en el grupo RSFF (P<0,05). MPF contribuye a una mejor apariencia, mejor recuperación sensorial y un bajo riesgo de ulceración a largo plazo, mientras que RSFF es adecuado para lesiones con defectos grandes o localizados en la parte lateral del talón.

Supervivencia de injerto graso en la lipotransferencia glútea / Survival of fat graft in gluteal lipotransfer

Introducción: El aumento de glúteos tiene como objetivo lograr una apariencia y contorno más joven; así como crear la proporción ideal entre cintura y cadera. Esto se puede lograr mediante la lipoinyección, aunque en este caso existen controversias en cuanto a la viabilidad del tejido injertado y la supervivencia de la grasa. Objetivo: Determinar el porcentaje de supervivencia del injerto de grasa autóloga y su relación con el volumen inyectado en pacientes sometidas a lipotransferencia glútea. Métodos: Se realizó un estudio observacional, descriptivo, de corte longitudinal y prospectivo con una muestra de 44 pacientes sometidas a lipotransferencia glútea en el Servicio de Cirugía Plástica del Hospital Docente Clínico Quirúrgico Dr. Miguel Enríquez en el período comprendido entre marzo de 2018 y junio de 2021. Resultados: El estudio evidencia que, mediante ultrasonido y fórmulas, el volumen promedio y la altura de la de grasa en los glúteos se duplica en el posoperatorio mediato y disminuye en el posoperatorio tardío sin llegar a los valores del preoperatorio. Además, se estableció que cerca de la media del volumen de grasa autóloga injertada en los glúteos sobrevive de manera definitiva en el posoperatorio tardío. Además, quedó establecido que la relación entre el volumen infiltrado y la supervivencia del injerto de grasa autóloga es inversamente proporcional: mientras mayor es el volumen, menor es su supervivencia. Conclusiones: Solo la mitad del volumen de grasa autóloga injertada en los glúteos sobrevive de manera definitiva, y la supervivencia de la grasa es inversamente proporcional al volumen infiltrado(AU)

Introduction: Buttock augmentation aims to achieve a more youthful appearance and contour; as well as creating the ideal proportion between waist and hips. This can be achieved by lipoinjection, although in this case there are controversies regarding the viability of the injected tissue and the survival of the fat. Objective: To determine the percentage of autologous fat graft survival and its relationship with the injected volume in patients undergoing gluteal fat transfer. Methods: An observational, descriptive, longitudinal and prospective study was carried out, with a sample of 44 patients undergoing gluteal lipotransfer, in the plastic surgery service of the Dr. Miguel Enriquez Clinical Surgical Teaching Hospital, in the intermediate period between March 2018 to June 2021. Results: The study shows that through ultrasound and formulas, the average volume and height of fat in the buttocks doubles in the immediate postoperative period, decreasing in the late postoperative period, without reaching preoperative values. Furthermore, it's established that about the mean volume of autologous fat grafted to the buttocks survives definitively in the late postoperative period. In addition, it was established that the relationship between the infiltrated volume and the survival of the autologous fat graft is inversely proportional, the greater the volume, the less its survival. Conclusions: Only half of the volume of autologous fat injected into the buttocks survives definitively, and the survival of the fat is inversely proportional to the volume injected(AU)

Nefrolitotomía Endoscópica ex vivo del injerto renal de donante vivo con instrumento flexible / Living-donor kidney graft ex vivo endoscopic nephrolithotomy with flexible instrument

INTRODUCTION: The finding of an asymptomatic stone in the study of a living kidney donor does not necessarily contraindicate donation, however, there is no consensus on the management of these cases. The use of a graft with lithiasis may represent a risk of recurrence in the remaining kidney in the donor and eventual obstructive complications in the transplanted kidney. The objective of this work is to present the usefulness of ureteroscopy (URS) to resolve lithiasis ex vivo before transplantation. MATERIAL AND METHODS: Donors with a small, asymptomatic kidney stone and with an analysis of lithogenic factors without relevant findings were considered to continue in the donation process. The kidney unit with stone was selected for nephrectomy. RESULTS: Four donor kidneys underwent flexible URS after nephrectomy under hypothermic preservation conditions during bench preparation. The average time of the procedure was 35 minutes and the stone was extracted in all cases without incident. The transplant was carried out in the usual way and the evolution of the recipients was without complications and with excellent renal function. During follow-up, no recurrence of lithiasis was observed in donors or recipients. CONCLUSIONS: In this experience, the URS of the donor kidney was a feasible procedure and was not associated with adverse consequences for the graft. The main advantage of this procedure is to avoid the potential risk to the recipient of an obstructive graft complication.

The dual mTORC1/2 inhibitor AZD2014 inhibits acute graft rejection in a rat liver transplantation model / 南方医科大学学报

OBJECTIVE@#To investigate the inhibitory effect of AZD2014, a dual mTORC1/2 inhibitor, against acute graft rejection in a rat model of allogeneic liver transplantation.@*METHODS@#Liver transplantation from Lewis rat to recipient BN rat (a donor-recipient combination that was prone to induce acute graft rejection) was performed using Kamada's two-cuff technique. The recipient BN rats were randomized into 2 groups for treatment with daily intraperitoneal injection of AZD2014 (5 mg/kg, n=4) or vehicle (2.5 mL/kg, n=4) for 14 consecutive days, starting from the first day after the transplantation. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBIL) levels of the rats were measured 3 days before and at 1, 3, 5, 7, 10, and 14 days after the transplantation, and the survival time of the rats within 14 days were recorded. Immunohistochemical staining was used to examine the expressions of CD3 and Foxp3 in the liver graft, and acute graft rejection was assessed using HE staining based on the Banff schema.@*RESULTS@#Three rats in the control group died within 14 days after the surgery, while no death occurred in the AZD2014 group, demonstrating a significantly longer survival time of the rats in AZD2014 group (χ2=4.213, P=0.04). Serum ALT, AST and TBIL levels in the control group increased progressively after the surgery and were all significantly higher than those in AZD2014 group at the same time point (P < 0.05). Pathological examination revealed significantly worse liver graft rejection in the control group than in AZD2014 group based on assessment of the rejection index (P < 0.01); the rats in the control group showed more serious T lymphocyte infiltration and significantly fewer Treg cells in the liver graft than those in AZD2014 group (P < 0.01).@*CONCLUSIONS@#AZD2014 can effectively inhibit acute graft rejection in rats with allogeneic liver transplantation.

Desenlaces a largo plazo en pacientes trasplantados renales con donantes de criterios expandidos: experiencia de 10 años / Long-term outcomes in kidney transplant patients with expanded criteria donors: 10-year experience

Introducción. El trasplante renal es el tratamiento de elección para la enfermedad renal crónica. Debido a la brecha con la disponibilidad de donantes, el uso de criterios expandidos es una opción que busca mejorar la tasa de donación mundial. El objetivo de este estudio fue comparar la sobrevida del injerto y del paciente trasplantado con donante de criterios expandidos versus el donante estándar. Métodos. Cohorte retrospectiva de 1002 pacientes con trasplante renal donde se determinó la sobrevida del injerto renal y del receptor a 10 años después del trasplante. La sobrevida del injerto renal y el receptor fueron estimadas por el método de Kaplan-Meier. Una regresión de Cox fue realizada ajustando el modelo multivariado.Resultados. El análisis incluyó 1002 receptores, con un 18,8 % (n=189) que correspondían al uso de donante de criterios expandidos. El grupo de trasplante renal con donante de criterios expandidos tuvo menor sobrevida del paciente (48,1 % versus 63,8 %) y del injerto (63,3 % versus 74,7 %) en comparación con el grupo de trasplante renal con donantes con criterios estándar a los 10 años después del trasplante. La asociación de trasplante renal con donante de criterios expandidos y muerte o pérdida del injerto renal no fueron significativas cuando se ajustaron las variables en el modelo multivariado. Conclusión. El trasplante renal con donante de criterios expandidos tiene menor sobrevida del receptor y del injerto frente al grupo de trasplante renal con donante estándar. No hubo diferencias estadísticamente significativas en cuanto al trasplante renal con donante de criterios expandidos frente a la pérdida del injerto renal o muerte.

Introduction. Kidney transplantation is the treatment of choice for chronic kidney disease. Due to the gap with donor availability, the use of expanded criteria is an option that seeks to improve the global donation rate. The objective of this study was to compare the survival of the graft and the transplanted patient with an expanded criteria donor versus the standard donor. Methods. Retrospective cohort of 1002 kidney transplant patients where survival of the kidney graft and the recipient was determined at 10 years after transplantation. The survival of the kidney graft and the recipient were estimated by the Kaplan-Meier method. A Cox regression was performed by fitting the multivariate model. Results. The analysis included 1002 recipients with 18.8% (n=189) corresponding to the use of an expanded criteria donor. The expanded criteria donor kidney transplant group had lower patient (48.1% versus 63.8%) and graft (63.3% versus 74.7%) survival compared to the donor kidney transplant group with standard criteria at 10 years post-transplant. The association of kidney transplantation with expanded criteria donor and death or loss of the kidney graft were not significant when the variables were adjusted in the multivariate model. Conclusion. Kidney transplantation with an expanded criteria donor has a lower recipient and graft survival compared to the standard kidney transplant group. There were no statistically significant differences in expanded criteria donor kidney transplantation versus kidney graft loss or death.

Supervivencia del paciente trasplantado y del injerto renal en una cohorte retrospectiva en México / Transplant patient and kidney graft survival in a retrospective cohort in Mexico

Introducción: el conocimiento de la funcionalidad del injerto y la supervivencia del paciente es fundamental para valorar el éxito del trasplante renal. Objetivo: determinar la supervivencia de los pacientes trasplantados por tipo de donante y la funcionalidad de los injertos renales en una cohorte en México. Material y métodos: cohorte de trasplante renal de 2013 a 2017 en México. Se analizaron 790 pacientes seguidos por un año para valorar la supervivencia de los pacientes trasplantados por tipo de donante y la funcionalidad de los injertos renales. Para ello se usaron medidas de tendencia central y dispersión, así como tablas de supervivencia de Kaplan-Meier con SPSS, versión 25. Resultados: de los 790 pacientes, 518 fueron de donante vivo (65.56%) con supervivencia del paciente de 97.88% y de funcionalidad del injerto de 93.24% a 12 meses de seguimiento; 272 pacientes recibieron el injerto de donante fallecido con supervivencia del paciente de 91.18% y funcionalidad del injerto renal de 84.19%. Conclusiones: aún existe una diferencia de casi 5% en la supervivencia del paciente receptor de un donante vivo en referencia con un donante fallecido. Para la funcionalidad del injerto renal esta diferencia es > 7%. La donación cadavérica ha aumentado; sin embargo, incluso en cifras bajas es de aproximadamente el 35% en México

Background: Knowledge of the functionality of the graft and patient survival is essential to assess the success of kidney transplantation. Objective: To determine the survival of transplanted patients by type of donor and the functionality of kidney grafts in a cohort in Mexico. Material and methods: Kidney transplant cohort from 2013 to 2017 in Mexico. 790 patients followed up for one year were analyzed to assess the survival of transplanted patients by type of donor and the functionality of kidney grafts. For this, measures of central tendency and dispersion were used, as well as Kaplan-Meier survival tables with SPSS, version 25. Results: Out of the 790 patients, 518 were from living donors (65.56%) with patient survival of 97.88% and graft function of 93.24% at 12 months of follow-up; 272 patients received the graft from a deceased donor with patient survival of 91.18% and renal graft function of 84.19%. Conclusions: There is still a difference of almost 5% in the survival of the recipient patient from a living donor compared to a deceased donor. For the functionality of the kidney graft, this difference is > 7%. Cadaveric donation has increased; however, even at low figures is of approximately 35% in Mexico

Cuidados de enfermería al paciente trasplantado renal período pre-operatorio, pos trasplante inmediato y temprano en la Unidad de Trasplante Renal del Hospital de Especialidades Carlos Andrade Marín / Nursing care of the renal transplant patient pre-operative, immediate posttransplant and early post-transplant periods in the Renal Transplant Unit of the Carlos Andrade Marín Specialties Hospital

El trasplante renal es considerado como la mejor alternativa de tratamiento sustitutivo para la enfermedad renal crónica terminal (ERCT)1, es el procedimiento quirúrgico que consiste en reemplazar un riñón sano de un donante vivo o cadavérico a una persona con diagnóstico de ERCT, que ayuda a mejorar su calidad de vida, la reinserción a sus actividades sociales, físicas, emocionales, laborales y sexuales. La Organización Nacional de Trasplantes de España (ONT) en el año 2018, reportó que en la Unión Europea se realizaron 21 102 y en Latinoamérica 12 806 trasplantes renales2, en Ecuador el Ministerio de Salud Pública (MSP) en los años 2007-2020 reportó un total de 1 6153, le correspondió al Hospital de Especialidades Carlos Andrade Marín (HECAM) el 32% del total de trasplantes renales realizados entre el periodo 2007-20184. La evaluación del potencial receptor es realizada por un equipo multidisciplinario con formación académica, experiencia certificada en los diferentes procesos y acreditados por el Instituto Nacional de Donación y Trasplantes (INDOT)5. Los cuidados de enfermería enmarcados en esta ruta, son especializados e integrales, que incluyen los períodos pre operatorio, pos trasplante inmediato y temprano al incorporar además un proceso educativo entre enfermera, paciente y familia/ cuidador, con el fin de preservar la sobrevida del injerto.

Renal transplantation is considered the best alternative replacement treatment for end-stage chronic kidney disease (ESRD)1, it is the surgical procedure that consists of replacing a healthy kidney from a living or cadaveric donor to a person diagnosed with ESRD, which helps to improve their quality of life, reintegration to their social, physical, emotional, work and sexual activities. The National Transplant Organization of Spain (ONT) in 2018, reported that In the European Union 21 102 and in Latin America 12 806 renal transplants were performed2, in Ecuador the Ministry of Public Health (MSP) in the years 2007-2020 reported a total of 1 6153, corresponded to the Carlos Andrade Marín Specialties Hospital (HECAM) 32% of the total number of renal transplants performed between 2007-20184. The evaluation of the potential recipient is performed by a multidisciplinary team with academic training, certified experience in the different processes and accredited by the National Institute of Donation and Transplantation (INDOT)5. The nursing care framed in this route is specialized and comprehensive, including the pre-operative, immediate post-transplant and early post-transplant periods, incorporating an educational process between nurse, patient and family/caregiver, in order to preserve graft survival.

Comparative analysis of kidney transplant costs related to recovery of renal function after the procedure / Análise comparativa dos custos do transplante renal relacionados à recuperação da função renal após o procedimento

Abstract Introduction: The number of kidney transplants (KTx) is increasing in Brazil and, consequently, the costs of this procedure increase the country's health budget. We retrospectively evaluated the data of kidney transplant procedures until hospital discharge, according to kidney function recovery after the procedure. Methods: Retrospective analysis of the non-sensitized, 1st KTx from deceased donors performed between Jan/2010 to Dec/2017. Results: Out of the 1300 KTx from deceased donors performed in this period, 730 patients were studied and divided into 3 groups: Immediate Renal Function (IRF) - decrease in serum creatinine ≥ 10% on two consecutive days; Delayed Graft Function (DGF) - decrease in serum creatinine <10% on two consecutive days, without the need for dialysis, and Dialysis (D) - need for dialysis during the first week. Patients in group D stayed longer in the hospital compared to DGF and IRF (21, 11 and 8 days respectively, p < 0.001). More D patients (21%) were admitted to the ICU and performed a greater number of laboratory tests (p < 0.001) and renal biopsies (p < 0.001), in addition to receiving a higher amount of immunosuppressants. Total hospital costs were higher in group D and DGF compared to IRF (U$ 7.021,48; U$ 3.603,42 and U$ 2.642,37 respectively, p < 0.001). Conclusion: The costs of the transplant procedure is impacted by the recovery of kidney function after the transplant. The reimbursement for each of these different kidney function outcomes should be individualized in order to cover their real costs.

Resumo Introdução: O número de transplantes renais (KTx, do inglês kidney transplant) está aumentando no Brasil e, consequentemente, os custos deste procedimento aumentam o orçamento de saúde do país. Avaliamos retrospectivamente dados dos procedimentos de transplantes renais até a alta hospitalar, de acordo com a recuperação da função renal após o procedimento. Métodos: Análise retrospectiva dos 1º KTx de doadores falecidos, não sensibilizados, realizados entre Jan/2010 a Dez/2017. Resultados: Dos 1300 KTx de doadores falecidos realizados neste período, 730 pacientes foram estudados e divididos em 3 grupos: Função Renal Imediata (FRI) - diminuição na creatinina sérica ≥ 10% em dois dias consecutivos; Função Retardada do Enxerto (FRE) - diminuição na creatinina sérica <10% em dois dias consecutivos, sem necessidade de diálise, e Diálise (D) - necessidade de diálise durante a primeira semana. Pacientes no grupo D permaneceram mais tempo no hospital em comparação com FRE e FRI (21, 11 e 8 dias dias respectivamente, p < 0,001). Mais pacientes do grupo D (21%) foram admitidos na UTI e realizaram um maior número de testes laboratoriais (p < 0,001) e biópsias renais (p < 0,001), além de receberem uma quantidade maior de imunossupressores. Os custos hospitalares totais foram mais elevados nos grupos D e FRE em comparação com FRI (U$ 7.021,48; U$ 3.603,42 e U$ 2.642,37 respectivamente, p < 0,001). Conclusão: Os custos do procedimento de transplante são impactados pela recuperação da função renal após o transplante. O reembolso para cada um desses diferentes desfechos da função renal deve ser individualizado a fim de cobrir seus custos reais.

Reconstrucción en amputaciones distales de dedos en niños con injerto compuesto y vendaje semioclusivo / Reconstruction of distal finger amputations in children with composite autograft and semi-oclusive dressing

La reconstrucción de una amputación distal de dedo en un niño es un desafío. Los procedimientos propuestos son muchos, y los resultados no han sido buenos. La reconstrucción con reposición del segmento a modo de injerto compuesto, o con técnicas microquirúrgicas, parece ofrecer la mejor de las posibilidades, pues se conservan estructuras irremplazables, como el lecho ungueal y el hiponiquio, lo que permite que los niños mantengan un pulpejo anatómico y con función normal. Presentamos una serie de tres pacientes pediátricos tratados con una nueva técnica, que combina la reposición del segmento, como un injerto compuesto, y el uso de curación semioclusiva (composite autograft and semi-oclussive dressing, CASOD, en inglés). Hemos observado buenos resultados.

The reconstruction of finger tip amputation in children is challenging. There are many procedures described to treat this injury, none of which present optimal results. Repositioning of the amputated segment as an autograft or with microsurgical techniques seems to offer the best outcome. It enables the preservation of otherwise irreplaceable structures, such as the nail bed and the hyponychium, thus enabling children to mantain an anatomically and functionally normal finger pad. We present a series of three pediatric patients treated with tha new technique, which combines composite autograft and semi-oclusive dressing (CASOD). The results observed so far have been promising.

The sum of kidney donor profile index and estimated post-transplant survival scale and their correlation with egfr decline in deceased donor kidney recipients

Background: The impact of donor quality on post-kidney transplant survival may vary by candidate condition. Objective: Analyzing the combined use of the Kidney Donor Profile Index (KDPI) and the estimated post-transplant survival (EPTS) scale and their correlation with the estimated glomerular filtration rate (eGFR) decline in deceased-donor kidney recipients (DDKR). Methods: This was a retrospective, observational cohort study. We included DDKRs between 2015 and 2017 at a national third-level hospital. Results: We analyzed 68 DDKR. The mean age at transplant was 41 ± 14 years, 47 (69%) had sensitization events, 18 (26%) had delayed graft function, and 16 (23%) acute rejection. The graft survival at 12 and 36 months was 98.1% (95% CI 94-100) and 83.7% (95% CI 65-100), respectively. The Pearson correlation coefficient between the percentage reduction in the annual eGFR and the sum of EPTS and KDPI scales was r = 0.61, p < 0.001. The correlation coefficient between the percentage reduction in the annual eGFR and the EPTS and KDPI scales separately was r = 0.55, p < 0.001, and r = 0.53, p < 0.001, respectively. Conclusions: The sum of EPTS and KDPI scales can provide a better donor-recipient relationship and has a moderately positive correlation with the decrease in eGFR in DDKR.

Dezesseis Anos de Transplante Cardíaco em Coorte Aberta no Brasil: Análise de Sobrevivência de Pacientes em Uso de Imunossupressores / Sixteen Years of Heart Transplant in an Open Cohort in Brazil: Analysis of Graft Survival of Patients using Immunosuppressants

Resumo Fundamento: O transplante cardíaco é a principal alternativa terapêutica para pacientes com insuficiência cardíaca avançada. Diversos fatores de risco influenciam a sobrevivência desses pacientes, entretanto, poucos estudos acerca do tema estão disponíveis no Brasil. Objetivos: Analisar a sobrevivência de pacientes transplantados cardíacos pelo Sistema Único de Saúde no Brasil entre 2000-2015. Métodos: Trata-se de uma coorte não concorrente, aberta, de pacientes transplantados cardíacos no Brasil. A probabilidade acumulada de sobrevivência foi estimada por Kaplan-Meier e a comparação entre as curvas realizada pelo Teste de Log-Rank. O modelo de Cox foi utilizado para calcular o Hazard-Ratio (HR). As análises foram realizadas ao nível de 95% de confiança. Resultados: A mediana de sobrevivência do transplante cardíaco no Brasil no período foi 8,3 anos. Cada ano adicional na idade do receptor, a ocorrência de infecções e a realização do procedimento cirúrgico na região Sul relacionaram-se ao maior risco de perda do enxerto. Maior proporção de uso dos imunossupressores micofenolato e azatioprina atuou como fator protetor. Conclusões: As análises realizadas fornecem a primeira informação quanto ao tempo de sobrevivência mediana do transplante cardíaco no Brasil. A diferença observada entre as regiões pode estar relacionada aos diferentes protocolos de tratamento adotados no país, principalmente no início dos anos 2000. A proporção de uso de micofenolato e azatioprina como fator protetor sugere que, apesar de não haver diferença entre as estratégias terapêuticas, o uso desses medicamentos pode favorecer a sobrevida de determinados pacientes. O estudo apresenta dados epidemiológicos robustos e importantes para a saúde pública.

Abstract Background: Heart transplant is the main therapeutic alternative for advanced heart failure patients. Several risk factors affect these patients' survival; however, few studies about the topic are available in Brazil. Objectives: To review the survival rates of heart transplant patients in the Brazilian Public Health System (Sistema Único de Saúde - SUS) between 2000 and 2015. Methods: This is a non-concurrent, open cohort study, involving cardiac transplant patients in Brazil. The cumulative survival probability was estimated by the Kaplan-Meier curve, and the curve comparison was done using the Log-Rank test. The Cox model was used to calculate the Hazard-Ratio (HR). Analyses were conducted at the 95% confidence level. Results: The heart transplant survival rate median in Brazil, during the period, was 8.3 years. Each additional year in the recipient's age, the occurrence of infections, and the performance of the surgical procedure in the South Region were associated with a higher risk of graft loss. A higher use ratio of immunosuppressants mycophenolate and azathioprine acted as a protection factor. Conclusions: The analyses conducted provide the first information about the median survival time in heart transplant patients in Brazil. The difference noticed among the geographical regions may be related to the different treatment protocols adopted in the country, especially in the early 2000s. The rate of mycophenolate and azathioprine use as a protection factor suggests that, despite the absence of differences among therapeutic strategies, use of these drugs may favor survival of certain patients. The study provides robust epidemiological data, which are relevant for public health.

Predictive value of hypothermic machine perfusion parameters combined perfusate biomarkers in deceased donor kidney transplantation / 中华医学杂志(英文版)

BACKGROUND@#Delayed graft function (DGF) is the main cause of renal function failure after kidney transplantation. This study aims at investigating the value of hypothermic machine perfusion (HMP) parameters combined with perfusate biomarkers on predicting DGF and the time of renal function recovery after deceased donor (DD) kidney transplantation.@*METHODS@#HMP parameters, perfusate biomarkers and baseline characteristics of 113 DD kidney transplantations from January 1, 2019 to August 31, 2019 in the First Affiliated Hospital of Xi'an Jiaotong University were retrospectively analyzed using univariate and multivariate logistic regression analysis.@*RESULTS@#In this study, the DGF incidence was 17.7% (20/113); The multivariate logistic regression results showed that terminal resistance (OR: 1.879, 95% CI 1.145-3.56) and glutathione S-transferase (GST)(OR = 1.62, 95% CI 1.23-2.46) were risk factors for DGF; The Cox model analysis indicated that terminal resistance was an independent hazard factor for renal function recovery time (HR = 0.823, 95% CI 0.735-0.981). The model combining terminal resistance and GST (AUC = 0.888, 95% CI: 0.842-0.933) significantly improved the DGF predictability compared with the use of terminal resistance (AUC = 0.756, 95% CI 0.693-0.818) or GST alone (AUC = 0.729, 95% CI 0.591-0.806).@*CONCLUSION@#According to the factors analyzed in this study, the combination of HMP parameters and perfusate biomarkers displays a potent DGF predictive value.

Early stage of antibody-mediated rejection after lung transplantation： A case report and literature review / 中南大学学报(医学版)

Antibody-mediated rejection (AMR) is a rare and serious complication after lung transplantation, with no characteristic of pathological manifestation, no systematic standard treatment, and the poor efficacy and prognosis. We reported a case of early AMR after lung transplantation and the relevant literature has been reviewed. A male patient presented with symptoms of cold 99 days after transplantation and resolved after symptomatic treatment. He admitted to the hospital 14 days later because of a sudden dyspnea and fever. Anti-bacteria, anti-fungi, anti-virus, and anti-pneumocystis carinii treatment were ineffective, and a dose of 1 000 mg methylprednisolone did not work too. The patient's condition deteriorated rapidly and tracheal intubation was done to maintain breathing. Serum panel reactive antibody and donor specific antibody showed postive in humen leukocyte antigen (HLA) II antibody. Pathological examination after transbronchial transplantation lung biopsy showed acute rejection. Clinical AMR was diagnosed combined the donor-specific antibody with the pathological result. The patient was functionally recovered after combined treatment with thymoglobuline, rituximab, plasmapheresis, and immunoglobulin. No chronic lung allograft dysfunction was found after 3 years follow up. We should alert the occurrence of AMR in lung transplantation recipient who admitted to hospital with a sudden dyspnea and fever while showed no effect after common anti-infection and anti-rejection treatment. Transbronchial transplantation lung biopsy and the presence of serum donor-specific antibody are helpful to the diagnosis. The treatment should be preemptive and a comprehensive approach should be adopted.

Techniques of orthotopic renal transplantation. II. Size-matched porcine grafts in monkey recipients

ABSTRACT Purpose As a classical xenotransplantation model, porcine kidneys have been transplanted into the lower abdomen of non-human primates. However, we have improved upon this model by using size-matched grafting in the orthotopic position. The beneficial aspects and surgical details of our method are reported herein. Methods Donors were two newborn pigs (weighting 5 to 6 kg) and recipients were two cynomolgus monkeys (weighting, approximately, 7 kg). After bilateral nephrectomy, kidneys were cold-transported in Euro-Collins solution. The porcine kidney was transplanted to the site of a left nephrectomy and fixed to the peritoneum. Results Kidneys transplanted to the lower abdomen by the conventional method were more susceptible to torsion of the renal vein (two cases). In contrast, early-stage blood flow insufficiency did not occur in orthotopic transplants of theleft kidney. Conclusions Size-matched porcine-primate renal grafting using our method of transplanting tothe natural position of the kidneys contributes to stable post-transplant blood flow to the kidney.

An open-label randomized clinical trial to evaluate the efficacy of everolimus versus tacrolimus in triple maintenance immunosuppressive therapy for kidney transplant patients

Tacrolimus (TAC), a calcineurin inhibitor, and everolimus (EVL), an mTOR inhibitor, have been used as immunosuppressive (ISS) drugs in post-kidney transplantation therapy. The objective of this study was to compare the efficacy of EVL vs TAC in the ISS maintenance triple therapy. Ninety-seven kidney transplant patients, who received triple maintenance therapy with TAC, mycophenolate mofetil (MMF), and methyl prednisone (PRED), were evaluated. After four months of post-kidney transplant therapy, 30 patients enrolled in a randomized controlled clinical trial, in which 16 patients received TAC+MMF+PRED (cohort 1), and 14 patients switched to EVL+MMF+PRED (cohort 2). The patients were followed-up for 36 months. Two patients from cohort 1 lost their grafts after one year due to non-adherence. Two patients from cohort 2 had intolerance to mTOR inhibitors and were switched back to TAC from EVL. One case (6.25%) in cohort 1 and three cases (21.43%) in cohort 2 of acute T-cell-mediated rejection was observed. Antibody-mediated acute rejection (ABMAR) was observed in four patients (25.0%) in cohort 1, and antibody-mediated chronic rejection (ABMCR) was observed in two patients (12.50%). One patient from cohort 2 lost the graft after 15 months due to polyomavirus infection. The graft survival rate was 87.50% in cohort 1 and 92.86% in cohort 2. This clinical trial showed that the EVL+MMF+PRED triple maintenance therapy was efficacious compared with TAC during 32 months of follow-up. However, further studies are needed to confirm the efficacy of this regimen for long-term graft survival.

Usefulness of Kidney Donor Profile Index (KDPI) to predict graft survival in a South Brazilian Cohort / Utilidade do Índice de Perfil de Doadores de Rins (KDPI) para prever a sobrevida do enxerto em uma coorte do Sul do Brasil

Abstract Introduction: Kidney Donor Profile Index (KDPI) has been incorporated in the United States to improve the kidney transplant allocation system. Objectives: To evaluate deceased kidney donors' profile using KDPI and compare to the previous United Network for Organ Sharing (UNOS) definition of expanded criteria donors (ECD) and assess the KDPI applicability to predict five-year graft survival and renal function in our sample. Methods: Retrospective cohort of 589 kidney transplants from deceased donors performed from January 2009 to May 2013 with follow-up until May 2018. Results: In 589 kidney transplants, 36.6% of donors were classified as ECD and 28.8% had KDPI ≥ 85%. Mean KDPI was 63.1 (95%CI: 60.8-65.3). There was an overlap of standard and ECD in KDPI between 60 and 95 and a significantly lower death-censored graft survival in KDPI ≥ 85% (78.6%); KDPI 0-20: 89.8%, KDPI 21-59: 91.6%, and KDPI 60-84: 83.0%; p = 0.006. The AUC-ROC was 0.577 (95%CI: 0.514-0.641; p = 0.027). Renal function at 5 years was significantly lower according to the incremental KDPI (p < 0.002). KDPI (HR 1.011; 95%CI 1.001-1.020; p = 0.008), donor-specific antibodies (HR 2.77; 95%CI 1.69-4.54; p < 0.001), acute rejection episode (HR 1.73; 95%CI 1.04-2.86; p = 0.034) were independent and significant risk factors for death-censored graft loss at 5 years. Conclusion: In our study, 36.6% were classified as ECD and 28.8% had KDPI ≥ 85%. KDPI score showed a moderate power to predict graft survival at 5 years. Renal function was significantly lower in patients with higher KDPI.

Resumo Introdução: O Índice de Perfil de Doadores de Rins (KDPI) foi adotado nos Estados Unidos para melhorar o sistema de alocação de transplantes renais. Objetivos: avaliar o perfil dos doadores de rim falecidos usando o KDPI e comparar com a definição anterior do United Network for Organ Sharing (UNOS) de doadores de critérios expandidos (DCE) e avaliar a aplicabilidade do KDPI para prever a sobrevida do enxerto em cinco anos e a função renal em nossa amostra. Métodos: Coorte retrospectiva de 589 transplantes renais de doadores falecidos, realizada de janeiro de 2009 a maio de 2013, com acompanhamento até maio de 2018. Resultados: Em 589 transplantes renais, 36,6% dos doadores foram classificados como DCE e 28,8% apresentaram KDPI ≥ 85%. O KDPI médio foi de 63,1 (IC 95%: 60,8-65,3). Houve uma sobreposição de padrão e DCE no KDPI entre 60 e 95 e uma sobrevida do enxerto censurada por óbito significativamente menor no KDPI ≥ 85% (78,6%); KDPI 0-20: 89,8%, KDPI 21-59: 91,6% e KDPI 60-84: 83,0%; p = 0,006. A ASC-ROC foi de 0,577 (IC 95%: 0,514-0,641; p = 0,027). A função renal aos 5 anos foi significativamente menor de acordo com o aumento do KDPI (p <0,002). KDPI (HR 1.011; 95% CI 1.001-1.020; p = 0.008), anticorpos específicos contra doadores (HR 2,77; 95% CI 1,69-4,54; p <0,001), episódio de rejeição aguda (HR 1,73; 95% CI 1,04-2,86; p = 0,034) foram fatores de risco independentes e significativos para perda do enxerto censurada por óbito em 5 anos. Conclusão: Em nosso estudo, 36,6% foram classificados como DCE e 28,8% apresentaram KDPI ≥ 85%. O escore KDPI mostrou potencial moderado para prever a sobrevida do enxerto em 5 anos. A função renal foi significativamente menor nos pacientes com maior KDPI.

Early Hospital Readmission (EHR) in kidney transplantation: a review article / Readmissão Hospitalar Precoce no transplante renal: artigo de revisão

Abstract Early hospital readmission (EHR), defined as all readmissions within 30 days of initial hospital discharge, is a health care quality measure. It is influenced by the demographic characteristics of the population at risk, the multidisciplinary approach for hospital discharge, the access, coverage, and comprehensiveness of the health care system, and reimbursement policies. EHR is associated with higher morbidity, mortality, and increased health care costs. Monitoring EHR enables the identification of hospital and outpatient healthcare weaknesses and the implementation of corrective interventions. Among kidney transplant recipients in the USA, EHR ranges between 18 and 47%, and is associated with one-year increased mortality and graft loss. One study in Brazil showed an incidence of 19.8% of EHR. The main causes of readmission were infections and surgical and metabolic complications. Strategies to reduce early hospital readmission are therefore essential and should consider the local factors, including socio-economic conditions, epidemiology and endemic diseases, and mobility.

Resumo A Readmissão Hospitalar Precoce (RH), definida como todas as readmissões dentro de 30 dias após a alta hospitalar inicial, é uma métrica da qualidade hospitalar. É influenciada pelas características demográficas da população em risco, pela abordagem multidisciplinar da alta hospitalar inicial, pelo acesso, pela cobertura e pela abrangência do Sistema de Saúde e pelas políticas de reembolso. A readmissão hospitalar precoce está associada a maior morbidade, mortalidade e aumento dos custos com saúde. O monitoramento da RH permite a identificação das fragilidades hospitalares e ambulatoriais e a implementação de intervenções corretivas. Entre os receptores de transplante renal nos EUA, a RH varia entre 18% e 47% e está associada a maior mortalidade e perda do enxerto no primeiro ano do transplante. Um estudo no Brasil mostrou uma incidência de 19,8% de RH. As principais causas de readmissão foram infecções e complicações cirúrgicas e metabólicas. As estratégias para reduzir a readmissão hospitalar precoce são, portanto, essenciais e devem considerar o ambiente local, incluindo condições socioeconômicas, epidemiologia local, doenças e mobilidade endêmicas.