RESUMO
BACKGROUND: The aim of this study was to evaluate the effect of ibandronate administration on long-term graft function and graft survival after successful renal transplantation. METHODS: Seventy-two renal transplant recipients (36 patients each in the treatment and control group) were included and followed over a 15-year period. Data on graft function and death-censored transplant outcome were recorded at 1, 5, 10, and 15 years. RESULTS: Death-censored Kaplan-Meier analysis showed significantly improved graft survival of the treatment group (p = 0.026), whereas Cox regression analysis showed that ibandronate was positively associated with improved transplant survival (p = 0.028, hazard ratio 0.24, 95% confidence interval 0.07-0.86). Although general linear modelling did not indicate that ibandronate had a significant effect on transplant function (calculated using the estimated glomerular filtration rate according to Chronic Kidney Disease Epidemiology Collaboration equation) over the entire 15-year period (p = 0.650), there was a tendency towards improved graft function 1-year post-transplantion (p = 0.056). CONCLUSIONS: Ibandronate treatment within the first year of transplantation resulted in a trend towards better graft function within the first few year post-transplant, and was associated with increased transplant survival at long-term follow-up.
Assuntos
Difosfonatos/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Fatores Imunológicos/uso terapêutico , Rim/efeitos dos fármacos , Macrófagos/efeitos dos fármacos , Monócitos/efeitos dos fármacos , Adulto , Difosfonatos/efeitos adversos , Feminino , Seguimentos , Alemanha , Taxa de Filtração Glomerular/efeitos dos fármacos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/fisiopatologia , Humanos , Ácido Ibandrônico , Fatores Imunológicos/efeitos adversos , Estimativa de Kaplan-Meier , Rim/imunologia , Rim/fisiopatologia , Transplante de Rim/efeitos adversos , Modelos Lineares , Macrófagos/imunologia , Masculino , Pessoa de Meia-Idade , Monócitos/imunologia , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Fatores de Risco , Linfócitos T Auxiliares-Indutores/efeitos dos fármacos , Linfócitos T Auxiliares-Indutores/imunologia , Fatores de Tempo , Resultado do TratamentoAssuntos
Calciofilaxia/patologia , Úlcera Cutânea/patologia , Anticoagulantes/uso terapêutico , Calciofilaxia/complicações , Humanos , Hiperparatireoidismo Secundário/complicações , Falência Renal Crônica/complicações , Perna (Membro)/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Femprocumona/uso terapêutico , Radiografia , Diálise Renal , Úlcera Cutânea/etiologiaRESUMO
Obstructive sleep apnea and arterial hypertension are frequent diseases, but they are also often overlooked. There is a causal relationship of sleep apnea and hypertension. Undiagnosed sleep apnea is probably the most important reason for "essential" hypertension. It is important to identify these patients. All hypertensive patients should be asked for snoring, breathing arrest and daytime sleepiness, neck circumference should be measured, and an ambulant sleep apnea monitoring should be performed, if necessary. Especially patients with refractory hypertension or non-dippers should be screened for sleep apnea and patients with sleep apnea should be examined for arterial hypertension. Continuous positive airway pressure (CPAP) can effectively lower blood pressure in the hypertensive sleep apnea patient. This is especially true for the obstructive sleep apnea patient with refractory hypertension. CPAP therapy is probably the best therapy for sleep apnea-induced nocturnal blood pressure rises.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Hipertensão/terapia , Apneia do Sono Tipo Central/terapia , Apneia Obstrutiva do Sono/terapia , Diagnóstico Diferencial , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Hipertensão/etiologia , Programas de Rastreamento , Polissonografia , Apneia do Sono Tipo Central/complicações , Apneia do Sono Tipo Central/diagnóstico , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/diagnósticoRESUMO
BACKGROUND: Aspirin treatment has an undoubted beneficial impact on the progression of cardiovascular diseases. We hypothesized that aspirin also protects allograft function and survival in the context of chronic renal allograft dysfunction, which displays decisive pathophysiologic features that are similar to those involved in atherogenesis. METHODS: A retrospective, multivariate analysis was performed to assess the effect of low-dose aspirin treatment (100 mg/day) on allograft function and survival of 830 renal transplant recipients. Allograft function was evaluated by serum creatinine levels, urine protein levels, and the presence of hematuria. RESULTS: Median allograft survival time was significantly longer in patients receiving low-dose aspirin therapy compared with patients receiving no aspirin treatment (n=205, 13.8 +/- 2.6 vs. 7.8 +/- 0.3 years, n=625; adjusted relative risk=0.443, 95% confidence interval [0.323-0.608], P<0.0001). Statin treatment and a recent time point of transplantation, reflecting the qualitative advances of the applied immunosuppressive therapy, were further positive determinants of renal allograft survival. The number of antihypertensive agents, representing the extent of hypertension, was a negative determinant of allograft survival. Transplant function was better preserved in aspirin-treated patients, who displayed a slower increase of serum creatinine and less proteinuria and hematuria during the observation period. The duration of aspirin treatment was positively associated with better allograft function. CONCLUSIONS: Low-dose aspirin therapy substantially improves renal allograft function and allograft survival. These findings suggest that aspirin should be considered to complement long-term posttransplant medical treatment regimens.
Assuntos
Aspirina/uso terapêutico , Sobrevivência de Enxerto/fisiologia , Transplante de Rim/fisiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Transplante Homólogo/fisiologiaRESUMO
BACKGROUND: En bloc kidneys from pediatric donors are regarded as questionable with respect to the safety and quality of the transplant outcome. Therefore, we retrospectively studied graft outcome and graft function of our 56 en bloc kidneys transplanted in paraaortal position between 1992 and 1999. METHODS: Graft outcome of en bloc kidneys (group A) was compared with graft outcome of single cadaveric adult donor kidneys (group B). Matched pairs were generated regarding HLA-missmatch, cold ischemic time, recipient age, body mass index, and systolic arterial blood pressure. RESULTS: Allograft survival rates of pediatric en bloc kidneys at 1, 3, and 5 years were significantly lower (group A: 78, 70, 70% vs. group B: 92, 92, 81%, P<0.05). Lower survival rate was caused by a higher number of graft losses in the early postoperative period (group A: 21% vs. group B: 4%, P<0.01) due to vascular complications. Main risk factor for graft loss was donor age of less than 12 months. Five years after transplantation serum creatinine of pediatric en bloc kidneys was significantly better than of adult kidneys (0.9+/-0.06 vs. 1.8+/-0.2 mg/dl, P<0.001). CONCLUSION: En bloc kidneys show a high percentage of graft survival with excellent long-term graft function. However, the early postoperative period carries a higher risk of graft loss in very young donors due to vascular complications. In the face of donor shortage en bloc kidneys from pediatric donors can successfully be transplanted in a paraaortal position.
Assuntos
Sobrevivência de Enxerto , Transplante de Rim/métodos , Adulto , Pré-Escolar , Creatinina/sangue , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doadores de TecidosRESUMO
BACKGROUND: Chronic urticaria often points the way to the diagnosis of a systemic disease, particularly when urticarial vasculitis can be demonstrated. Hypocomplementemic urticarial vasculitis syndrome (HUVS) is considered to be an independent immunological disease. METHOD: Selective literature review and consideration of the author's own clinical experience. RESULTS AND CONCLUSIONS: The main manifestation of HUVS is chronic urticarial vasculitis with complement deficiency and the demonstration of C1q antibody in the serum. Multiple other organs are involved, sometimes severely. The diagnosis is confirmed by skin biopsy, which reveals leukocytoclastic vasculitis as a pathogenetic correlate of this systemic disease. Although HUVS is relatively rare, the medical specialists that might encounter it-ophthalmologists, rheumatologists, nephrologists, dermatologists, general practitioners, and pediatricians-should include it in their differential diagnoses whenever appropriate. Awareness of HUVS and rational diagnostic evaluation will lessen the chance of it being misdiagnosed as another type of systemic immunological disease and will reduce superfluous diagnostic testing in patients suffering from it.
Assuntos
Proteínas do Sistema Complemento/deficiência , Proteínas do Sistema Complemento/imunologia , Equipe de Assistência ao Paciente , Urticária/diagnóstico , Urticária/imunologia , Vasculite/diagnóstico , Vasculite/imunologia , Diagnóstico Diferencial , Humanos , SíndromeRESUMO
BACKGROUND: Patients with Wilson's disease may present with cirrhosis, acute hepatitis or fulminant hepatic failure. Without urgent orthotopic liver transplantation, a fulminant Wilson crisis has a mortality of 100%. We report on an 18-year-old female patient with fulminant hepatic failure due to Wilson crisis. METHODS: The molecular adsorbent recirculating system (MARS) was used to eliminate albumin-bound toxins and to bridge waiting until an organ became available. RESULTS: A total of 18 MARS sessions and 4 plasma exchange sessions were performed. Bilirubin levels and hepatic encephalopathy improved under MARS therapy. A total of 75 mg copper was removed until serum copper levels were within the normal range. Copper elimination was measured in 15 MARS treatments, which removed a total of 12.9 mg copper. Four plasma exchange sessions, with a total exchange of 11 liters of plasma, removed 12 mg copper. Urinary copper elimination with penicillamine was 50 mg. CONCLUSION: MARS was an effective method to stabilize a patient with Wilson crisis, contributed to copper elimination and gained time for liver transplantation. The risk of high-urgency transplantation could be avoided. Liver support was easy in the hands of nephrologists familiar with extracorporeal therapy.
Assuntos
Degeneração Hepatolenticular/terapia , Falência Hepática/terapia , Diálise Renal , Adolescente , Bilirrubina/sangue , Cobre/sangue , Cobre/urina , Feminino , Encefalopatia Hepática/terapia , Humanos , Penicilamina/uso terapêutico , Troca PlasmáticaRESUMO
BACKGROUND AND AIMS: Elevated levels of renal tubular markers in the urine are found in 20-30% of patients with chronic inflammatory bowel diseases. We investigated whether this reflects a dose-dependent tubulotoxicity of 5-aminosalicylic acid (5-ASA). PATIENTS AND METHODS: In an open, prospective, multicenter study 18 patients with Crohn's disease and 29 with ulcerative colitis were treated with 3 g 5-ASA or more daily as the sole drug for 6 weeks. Clinical activity (CDAI, CAI) and renal tubular markers [beta-N-acetyl-D-glucosaminidase (beta-NAG) and other proteins in urine] were monitored. We examined whether the proportion of patients with elevated beta-NAG is more than 15% higher (absolute difference) than that prior to treatment. RESULTS: The proportion decreased from 19.2% to 12.8% in the intention-to-treat analysis (n=47) and from 24.3% to 13.5% in the per-protocol analysis (n=37), which was not more than 15% higher than at baseline. Mean CDAI decreased from 222 to 146 and mean CAI from 7.3 to 3.1 (intention-to-treat analysis). Response to therapy was shown by 61% of patients with Crohn's disease and 66% of patients with ulcerative colitis. The cumulative dose of 5-ASA was not correlated with beta-NAG level in the urine. CONCLUSION: This study largely rules out that 5-ASA at 3 g or higher per day for 6 weeks induces renal tubular damage. Elevated renal tubular markers reflect inflammatory activity or an extraintestinal manifestation of inflammatory bowel diseases.
Assuntos
Anti-Inflamatórios não Esteroides/administração & dosagem , Doença de Crohn/tratamento farmacológico , Hexosaminidases/urina , Túbulos Renais/efeitos dos fármacos , Mesalamina/administração & dosagem , Adulto , Biomarcadores/sangue , Biomarcadores/urina , Doença de Crohn/enzimologia , Doença de Crohn/imunologia , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Humanos , Masculino , Estudos Prospectivos , Receptores de Interleucina-2/sangue , Receptores do Fator de Necrose Tumoral/sangue , beta-N-Acetil-GalactosaminidaseRESUMO
BACKGROUND: Mortality or graft loss after renal transplantation might be influenced by hepatitis virus infection. METHODS: Sera from time of transplantation of 927 renal transplant recipients were tested for hepatitis C (HCV) and hepatitis B virus (HBV) in order to investigate the impact of hepatitis virus infection on graft loss and mortality over an observation period of 20 yr. RESULTS: One hundred and twenty three of 927 patients were HCV positive, 30 patients HBV positive and seven patients HBV and HCV positive. The observation period was 9.2 +/- 4.4 yr. Mortality was significantly higher in patients with hepatitis B (p = 0.0005), as well as in patients with concomitant B and C hepatitis (p < 0.0001) and in those who acquired HCV infection after transplantation (n = 30, p = 0.0192) compared with non-infected patients. Patients with replicating HBV infection (HBeAg positive) had the worst prognosis (p < 0.0001). In the multivariate analysis the presence of HBeAg (p < 0.0001), patients' age (p < 0.0001) and HCV infection after transplantation (p = 0.0453) were predictors for death. Graft survival was significantly shorter in patients with concomitant hepatitis B and C (p = 0.0087) as well as in HBeAg positive patients (p = 0.002). HCV infection or HBs antigenemia did not have a significant impact on graft survival compared with non-infected patients. CONCLUSION: HCV infection after transplantation is associated with a high mortality whereas chronic HCV infection before trans plantation does not have a significant impact on mortality. Patients with replicating HBV infection or concomitant HBV and HCV infection have a high risk of graft loss and mortality.
Assuntos
Sobrevivência de Enxerto , Hepatite B/diagnóstico , Hepatite C/diagnóstico , Transplante de Rim , Adulto , Feminino , Rejeição de Enxerto/virologia , Hepatite B/complicações , Antígenos da Hepatite B/sangue , Hepatite C/complicações , Anticorpos Anti-Hepatite C/sangue , Humanos , Transplante de Rim/mortalidade , Masculino , Fatores de Risco , Taxa de SobrevidaRESUMO
BACKGROUND: Chronic hepatitis C virus (HCV) infection is closely associated with mixed cryoglobulinemia. Cryoglobulins can activate complement leading to vascular damage. We examined whether cryoglobulinemia and complement turnover is associated with HCV infection in renal transplant recipients and whether this has an adverse effect on graft outcome. METHODS: Sera and fresh plasma from 31 HCV-RNA-positive patients after renal transplantation (group I) were studied for cryoglobulins, complement hemolytic activity (CH50), and complement split product C3d. In total, 80 HCV-negative renal transplant recipients (group II) and 72 untreated patients with chronic hepatitis C (group III) without renal transplantation served as controls. RESULTS: Cryoglobulins were detected in 45, 28, and 26% of the patients in group I, II, and III, respectively. A high cryocrit ( > 5%) was present only in patients of group III (p < 0.01%). Mean CH50 values were lower and C3d levels higher in HCV-positive patients (group I and III) compared with HCV-negative patients (p < 0.0001). Cryoglobulins were not associated with extrahepatic manifestations or graft dysfunction, except in five patients of group III demonstrating cryoglobulinemic vasculitis. HCV-positive renal transplant recipients with signs of complement activation showed a significantly greater increase of serum creatinine (0.88 +/- 1.14 mg/dL) when compared with baseline than patients without complement activation (0.34 +/- 0.37 mg/dL; p = 0.035). There was also a tendency toward a higher extent of proteinuria in patients with complement activation (1.38 +/- 2.17 g/d vs. 0.50 +/- 0.77 g/d; p = 0.25, NS). CONCLUSIONS: Cryoglobulins are common in renal allograft recipients, but do not affect graft function. However, complement activation appears to be involved in chronic allograft dysfunction in HCV-infected recipients.
Assuntos
Ativação do Complemento , Crioglobulinemia/imunologia , Crioglobulinas/imunologia , Hepatite C Crônica/imunologia , Transplante de Rim/imunologia , Adulto , Estudos de Casos e Controles , Complemento C3d/imunologia , Ensaio de Atividade Hemolítica de Complemento , Creatinina/sangue , Feminino , Humanos , Transplante de Rim/fisiologia , Masculino , Pessoa de Meia-IdadeRESUMO
Severe osteoporosis frequently is observed after organ transplantation. In kidney transplantation, it adds to pre-existing renal bone disease and strategies to prevent osteoporosis are not established. Eighty kidney recipients were included in a randomized controlled prospective intervention trial. Treated patients (n = 40) received an injection of ibandronate, a bisphosphonate, immediately before and at 3, 6, and 9 mo after transplantation. The primary outcome measured was the change in bone mineral density. Secondary measures included graft outcome, spinal deformities, fracture rate, body height, and hormonal and metabolic data. Loss of spongy and cortical bone after transplantation was prevented by ibandronate. Changes of bone mineral density (ibandronate versus controls) were as follows: lumbar spine, -0.9 +/- 6.1% versus -6.5 +/- 5.4% (P < 0.0001); femoral neck, +0.5 +/- 5.2% versus -7.7 +/- 6.5% (P < 0.0001); and midfemoral shaft, +2.7 +/- 12.2% versus -4.0 +/- 10.9% (P = 0.024). Fewer spinal deformities developed with ibandronate (7 patients with 7 deformities versus 12 patients with 23 deformities; P = 0.047). Loss of body height was 0.5 +/- 1.0 cm versus 1.1 +/- 1.0 cm in control subjects (P = 0.040). Two bone fractures occurred in each group. There were fewer acute rejection episodes with ibandronate (11 versus 22; P = 0.009). Graft function after 1 yr was comparable. Bone loss, spinal deformation, and loss of body height during the first year after kidney transplantation are prevented by injection of ibandronate at intervals of 3 mo. The smaller number of rejection episodes of the ibandronate-treated group should be confirmed and its mechanism should be explored in additional studies.