RESUMEN
BACKGROUND: Chronic kidney disease (CKD) is associated with reduction of fertility and increased complications during pregnancy. The aim of this work is to analyze the clinical outcomes and risk factors in pregnant women who needed to start dialysis with different schedules in a public hospital in Mexico City, with particular attention on the interference of social and cultural elements as well as resource limitations. MATERIAL AND METHODS: CKD women who needed dialysis in pregnancy over the period 2002â»2014 and had with complete demographic and outcome data were included in this retrospective study. Clinical background, renal function during pregnancy, dialysis schedule, and clinical outcomes were reviewed. RESULTS: Forty pregnancies in women with CKD who needed dialysis in pregnancy (39 singleton and one twin pregnancy) were studied: All patients were treated with hemodialysis. Thirty-nine patients had CKD stages 4 or 5 at referral; only one patient was of stage 3b. Dialysis was considered as indicated in the presence of fluid overload, unresponsive hypertension in the setting of advanced CKD, or when blood urea nitrogen values were increased to around 50 mg/dL. However, the initiation of dialysis was often delayed by days or weeks. The main reason for delaying the initiation of dialysis was patient (and family) refusal to start treatment. All patients were treated with thrice weekly dialysis, in 3â»5 hour sessions, with a target urea of <100 mg/dL. The number of hours on dialysis did not impact pregnancy outcomes. Ten pregnancies ended in miscarriages (8 spontaneous), 29 in pre-term delivery, and 1 in term delivery. Fifteen women were diagnosed with preeclampsia, one with eclampsia, and one with HELLP (hemolysis, elevated liver enzymes, low platelets,) syndrome. Twenty-four of the neonates survived (77.4% of live births); six singletons and one twin died as a consequence of prematurity. Two neonates displayed malformations: cleft palate with ear anomalies and duodenal atresia. CONCLUSIONS: CKD requiring hemodialysis in pregnancy is associated with a high frequency of complications; in the setting of delayed start and of thrice-weekly hemodialysis, dialysis schedules do not appear to influence outcomes.
RESUMEN
BACKGROUND: The incidence of cancer in transplant recipients is higher than in the general population. Cutaneous and lymphoproliferative tumors are the primary neoplasms that will develop these patients. Little is known about the transmission of cancer in organ and tissue donation; it has been described that neoplasms can be transmitted to immunosuppressed patients when donor organs with neoplasms are inadvertently transplanted. CASE REPORT: Patient of 29 years of age who underwent kidney transplantation 10 years ago. The kidney was donated by his father, who was 58 years. An incidental finding in the bench surgery showed a tumor of about 1 cm in the donated kidney. The intraoperative histopathological study showed no alterations, but two weeks after the surgery it was diagnosed follicular non-Hodgkin lymphoma grade II retroperitoneal. Subsequently, the donor underwent radiotherapy, since it was documented local growth of lymph. The recipient was monitored, given that the complete tumor was removed free of neoplasia in all its edges. 10 years after the transplantation, both donor and recipient are free of neoplastic disease and the latter has a stable renal function. CONCLUSIONS: In the presence of an incidental neoplasm from a renal donor, the possibility of donation must be reconsidered in the face of an in situ neoplasm. We suggest detailed protocol prior to transplant and a thorough exploration in the surgical event in order to detect tumors with intraoperative study.
INTRODUCCIÓN: la incidencia de cáncer en receptores de trasplante es más elevada que en la población general. Los tumores cutáneos y linfoproliferativos son las principales neoplasias que van a desarrollar estos pacientes. Poco se conoce de la transmisión de cáncer en la donación de órganos y tejidos; se ha descrito que las neoplasias pueden transmitirse a enfermos inmunosuprimidos cuando los órganos de donantes con neoplasia son trasplantados de forma inadvertida. CASO CLÍNICO: paciente de 29 años que fue sometido a trasplante renal hace 10 años. El riñón lo donó su padre, de 58 años. En cirugía de banco hubo hallazgo incidental de tumoración en riñón donado de aproximadamente 1 cm. El estudio histopatológico transoperatorio no presentó alteraciones, pero a las dos semanas se diagnosticó en el reporte definitivo linfoma no Hodgkin folicular grado II del retroperitoneal. Posteriormente el donante se sometió a tratamiento de radioterapia al documentarse ganglios locales crecidos y el receptor solo estuvo en vigilancia al extraerse tumoración completa libre de neoplasia en todos sus bordes. A 10 años del trasplante, ambos están libres de enfermedad neoplásica y el receptor tiene una función renal estable. CONCLUSIÓN: ante una neoplasia incidental de un donante renal, deberá replantearse la posibilidad de donación ante la posibilidad de un cáncer in situ. Sugerimos protocolo minucioso de diagnóstico previo al trasplante y una exploración minuciosa en evento quirúrgico con el fin de detectar tumoraciones con estudio transoperatorio.