Polyphenols: immunonutrients tipping the balance of immunometabolism in chronic diseases.

Mounting evidence progressively appreciates the vital interplay between immunity and metabolism in a wide array of immunometabolic chronic disorders, both autoimmune and non-autoimmune mediated. The immune system regulates the functioning of cellular metabolism within organs like the brain, pancreas and/or adipose tissue by sensing and adapting to fluctuations in the microenvironment's nutrients, thereby reshaping metabolic pathways that greatly impact a pro- or anti-inflammatory immunophenotype. While it is agreed that the immune system relies on an adequate nutritional status to function properly, we are only just starting to understand how the supply of single or combined nutrients, all of them termed immunonutrients, can steer immune cells towards a less inflamed, tolerogenic immunophenotype. Polyphenols, a class of secondary metabolites abundant in Mediterranean foods, are pharmacologically active natural products with outstanding immunomodulatory actions. Upon binding to a range of receptors highly expressed in immune cells (e.g. AhR, RAR, RLR), they act in immunometabolic pathways through a mitochondria-centered multi-modal approach. First, polyphenols activate nutrient sensing via stress-response pathways, essential for immune responses. Second, they regulate mammalian target of rapamycin (mTOR)/AMP-activated protein kinase (AMPK) balance in immune cells and are well-tolerated caloric restriction mimetics. Third, polyphenols interfere with the assembly of NLR family pyrin domain containing 3 (NLRP3) in endoplasmic reticulum-mitochondria contact sites, inhibiting its activation while improving mitochondrial biogenesis and autophagosome-lysosome fusion. Finally, polyphenols impact chromatin remodeling and coordinates both epigenetic and metabolic reprogramming. This work moves beyond the well-documented antioxidant properties of polyphenols, offering new insights into the multifaceted nature of these compounds. It proposes a mechanistical appraisal on the regulatory pathways through which polyphenols modulate the immune response, thereby alleviating chronic low-grade inflammation. Furthermore, it draws parallels between pharmacological interventions and polyphenol-based immunonutrition in their modes of immunomodulation across a wide spectrum of socioeconomically impactful immunometabolic diseases such as Multiple Sclerosis, Diabetes (type 1 and 2) or even Alzheimer's disease. Lastly, it discusses the existing challenges that thwart the translation of polyphenols-based immunonutritional interventions into long-term clinical studies. Overcoming these limitations will undoubtedly pave the way for improving precision nutrition protocols and provide personalized guidance on tailored polyphenol-based immunonutrition plans.

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss.

An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.

Current Challenges for Biological Treatment of Pharmaceutical-Based Contaminants with Oxidoreductase Enzymes: Immobilization Processes, Real Aqueous Matrices and Hybrid Techniques.

The worldwide access to pharmaceuticals and their continuous release into the environment have raised a serious global concern. Pharmaceuticals remain active even at low concentrations, therefore their occurrence in waterbodies may lead to successive deterioration of water quality with adverse impacts on the ecosystem and human health. To address this challenge, there is currently an evolving trend toward the search for effective methods to ensure efficient purification of both drinking water and wastewater. Biocatalytic transformation of pharmaceuticals using oxidoreductase enzymes, such as peroxidase and laccase, is a promising environmentally friendly solution for water treatment, where fungal species have been used as preferred producers due to their ligninolytic enzymatic systems. Enzyme-catalyzed degradation can transform micropollutants into more bioavailable or even innocuous products. Enzyme immobilization on a carrier generally increases its stability and catalytic performance, allowing its reuse, being a promising approach to ensure applicability to an industrial scale process. Moreover, coupling biocatalytic processes to other treatment technologies have been revealed to be an effective approach to achieve the complete removal of pharmaceuticals. This review updates the state-of-the-art of the application of oxidoreductases enzymes, namely laccase, to degrade pharmaceuticals from spiked water and real wastewater. Moreover, the advances concerning the techniques used for enzyme immobilization, the operation in bioreactors, the use of redox mediators, the application of hybrid techniques, as well as the discussion of transformation mechanisms and ending toxicity, are addressed.

Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review.

Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients' outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.

Kidney Retransplantation Outcomes: A Paired Recipient Control Study.

BACKGROUND: Despite progressive improvements in graft and patient survival after kidney transplantation over the last decades, an increasing number of patients are waitlisted for retransplantation. Identifying the risk factors for second graft failure can help us improve management for such patients. The aim of this study was to compare the outcomes of kidney retransplantation with those of first transplantation. METHODS: This retrospective study included all the recipients of a second kidney transplant between January 2008 and December 2019. For each patient with a second kidney transplant, we selected the paired recipient from the same donor. We excluded recipients of donations from living donors, patient-and-donor pairs with more than 1 transplant, and patients without a pair. The follow-up took place December 31, 2020. We included 152 patients, corresponding to 76 pairs of recipients. RESULTS: Patients who underwent a second transplant had significantly higher panel reactive antibody values and longer waiting time for retransplantation. Biopsy-proven acute rejection episodes were doubled in patients undergoing a second transplant (P = .12). There was a lower survival of second grafts at the first, fifth, and 10th year (P < .05). The main factor influencing graft loss for both groups was acute rejection, and, in patients, with a second transplant, acute rejection increased the risk of graft loss by 17 times (odds ratio, 17.5; 95% confidence interval, 4.19-98). CONCLUSIONS: The clinical results of second kidney transplants still fall short of first transplants, with the main factor of poor prognosis being acute rejection. In young patients, allocation and immunosuppression management should consider this risk to improve long-term outcomes.

Kidney Retransplant: Not Too Old for a Second Chance.

BACKGROUND: Kidney retransplant outcomes in the elderly are not well established. Our aim was to compare major clinical outcomes between patients older and younger than 60 years old at retransplant and between first and second kidney transplant (KT) for recipients older than 60 years old. METHODS: We performed a retrospective, longitudinal study that included all patients who underwent KT between January 2008 and December 2019. We defined 3 groups according to recipient age and retransplant status: group 1, patients ≥60 years old and retransplant; group 2, patients <60 years old and retransplant; group 3, patients ≥60 years old and first kidney transplant. We compared clinical outcomes such as acute rejection, death-censored graft survival, and patient survival between groups. RESULTS: We included 109 patients with a second KT, including 13 older than 60 years old (group 1) and 96 younger than 60 years old (group 2). There were no differences in death-censored graft survival or patient survival. There were no biopsy-proven acute rejections for older patients compared with 21 events in the younger group. Regarding differences between retransplant (group 1, n = 13) and first kidney transplant (group 3, n = 390) in patients older than 60 years old, there were no differences in death-censored graft survival at 1 and 5 years or in patient survival. CONCLUSIONS: In our study, major clinical outcomes of retransplant in the elderly were similar to those of their younger counterparts with a second graft and with those of older patients with a first graft.

The type of SARS-CoV-2 vaccine influences serological response in kidney transplant recipients.

Vaccination is a promising strategy to control the ongoing pandemic; however, solid organ recipients tend to develop a weaker immune response to vaccination. Anti-spike SARS-CoV-2 antibodies titers were measured 2-4 weeks post-vaccination completion in 131 KT patients without previous infection. Demographic, clinical, and laboratorial parameters were analyzed to identify which factors contributed to seroconversion. Factors that influenced seroconversion, that occurred in 76 patients (58%), were longer time post-transplant, immunosuppression without an antiproliferative drug and vaccination with mRNA vaccines. Patients who received mRNA vaccines had significantly higher rates of seroconversion compared with adenovirus vector vaccines (67% vs 33%, P < .001) and higher anti-spike IgG titers. These findings reinforce the need to discuss the vaccination strategy in this population, including a third dose with a mRNA vaccine.

Incidence, prevalence and crude survival of patients starting dialysis in Portugal (2010-16): analysis of the National Health System individual registry.

BACKGROUND: The Portuguese Society of Nephrology (PSN) reported that Portugal has one of the highest incidences of dialysis in Europe. However, this claim was based on aggregated data supplied by dialysis providers, hampering comparisons between countries. In 2009, an individual registry of patients starting dialysis was set up by the Portuguese Ministry of Health. We analysed individual data of patients starting dialysis from January 2010 until December 2016. METHODS: Demography, starting treatment day, modality, regional distribution and outcomes, such as death, recovery of renal function, transfer to renal transplantation, peritoneal dialysis or conservative management, were extracted. Incidence, prevalence and survival analysis were calculated and compared with the PSN registry. RESULTS: Out of 19 190 registrations, 16 775 were incident patients (61.8% men). Yearly incidence of renal replacement therapy was 250, 248, 229, 239, 230, 231 and 244 per million population (p.m.p.) for 2010 to 2016, compared with 235, 224, 218, 230, 234, 225 and 239 p.m.p. reported by the PSN registry. On the other hand, prevalence increased from 998 p.m.p. in 2010 to 1286 p.m.p. in 2016, compared with 1010 p.m.p. in 2010 increasing to 1203 p.m.p. in 2016 from the PSN registry. The regions of Alentejo (122.9 p.m.p.) and the the Centre (160.8 p.m.p.) had the lowest regional incidence, while Lisbon had the highest (386 p.m.p. in 2016). Unadjusted survival analysis revealed that 93.5% of the patients were alive on the 91st day, whereas 85.2 and 78.3% were alive at 1 and 2 years, respectively. Crude survival at 7 years was 40%. CONCLUSIONS: For the first time, an individual registry of patients starting dialysis in Portugal was subject to analysis and added new information about long-term survival and regional differences in the incidence and prevalence of renal replacement therapy. We were able to confirm that Portugal has one of the world's highest incidences and prevalences of dialysis. We also demonstrate, for the first time, a striking regional difference in the incidence of dialysis and an excellent early and long-term survival of patients on dialysis. These results compare well with other European countries in terms of the dialysis efficiency.

Borderline Changes in Renal Transplantation: Are We Aware of the Real Impact in Graft Survival?

BACKGROUND: Borderline changes suspicious for acute T-cell-mediated rejection (BC) are frequently seen on biopsy specimens, but their clinical significance and clinical management are still controversial. Our goal was to compare clinical outcomes of kidney transplant recipients with biopsy-proven BC vs acute T-cell-mediated rejection (aTCMR) and the influence of treating BC on graft outcomes. METHODS: A retrospective cohort study was performed in all kidney transplant recipients with biopsy-proven BC and aTCMR between January 2012 and December 2018, according to Banff 2017 criteria; patients with concomitant antibody-mediated rejection were excluded. RESULTS: We included 85 patients, 30 with BC (35.3%) and 55 with aTCMR (64.7%). There was no difference between groups regarding demographics, HLA matching and sensitization, immunosuppression, or time of transplant. Treatment with steroids was started in 15 patients with BC (50%) and in all patients with aTCMR, with 4 of the latter additionally receiving thymoglobulin (7.2%). At 1 year post biopsy, overall graft survival was 71%, and despite presenting better estimated glomerular filtration rate (eGFR) at biopsy (33.3 ± 23.4 vs 19.9 ± 13.2 mL/min/1.73 m2, P = .008), patients in the BC group presented the same graft survival as the aTCMR group according to Kaplan-Meyer survival curves. When analyzing the BC group (n = 30) and comparing the patients who were treated (n = 15) vs a conservative approach (n = 15), graft survival at 1 year was 87% for treated patients and 73% for nontreated patients (P = .651), with no difference in eGFR for patients with functioning graft. However, at longer follow-up, survival curves showed a trend for better graft survival in treated patients (70.2 ± 9.2 vs 38.4 ± 8.4 months, P = .087). CONCLUSION: Our study showed that patients with BC did not present better graft survival or graft function at 1 year after biopsy or at follow-up compared with the aTCMR group, despite better eGFR at diagnosis. We found a trend for better graft survival in patients with BC treated with steroids compared with a conservative approach. These results reinforce the importance of borderline changes in graft outcomes and that the decision to treat can influence long-term outcomes.

Hemodialysis Reliable Outflow graft: A valid option in patients with central venous stenosis.

INTRODUCTION: Central venous stenosis can be the main obstacle to the creation of an autologous vascular access in the upper limbs. The Hemodialysis Reliable Outflow graft was developed to provide an upper limb vascular access option to such patients, avoiding alternative, less advantageous options, such as lower limb vascular accesses or central venous catheters. Its advantages include catheter avoidance and, in case of lower limbs accesses, reduction of the ischemic risk and iliac vein thrombosis, potentially compromising a future kidney transplant. PATIENTS AND METHODS: Revision of the clinical files of the four patients who were placed a Hemodialysis Reliable Outflow device in our Center, including demographic variables, implantation technique characteristics, surgical complications, episodes of infection and thrombosis of the access, and need to place a transitory central venous catheter to undergo hemodialysis treatment. RESULTS: Four Hemodialysis Reliable Outflow grafts were placed, which resulted in a significant improvement in the dialysis efficacy in all patients, with a median raise in the Kt/V of 36.7%. Two cases needed thrombectomy, one of which was unsuccessful. The actual time of patency varies between 3 and 28 months. CONCLUSION: Our experience with the Hemodialysis Reliable Outflow device showed that it was a safe option for patients with central venous stenosis and was associated with good clinical and analytic outcomes.

Arteriovenous graft in kidney transplant patients: Lookout for the rare but fearsome angiosarcoma.

INTRODUCTION: Angiosarcomas are rare tumors, comprising less than 1% of all sarcomas. However, they portend a poor prognosis, as they tend to metastasize early, being of uttermost importance a prompt diagnosis and treatment. CASE DESCRIPTION: We present the case of a 55-year-old female with history of kidney transplantation, immunosuppressed with tacrolimus, prednisolone, and mofetil mycophenolate. Fifteen years after the transplant, she developed an ulcerated lesion on the site of a nonfunctioning arteriovenous graft, which was excised. Histology was compatible with a high grade angiosarcoma that invaded the margins, and immunosuppression was switched to everolimus. Staging imaging exams revealed lymph node, muscle, and lung metastases. Shortly after, nodular lesions appeared compatible with local recurrence of the disease, and the patient showed severe deterioration of her clinical condition, being proposed for palliative chemotherapy. However, the disease showed an explosive progression and the patient died before starting the treatment. CONCLUSION: This case emphasizes the importance of including inspection of the vascular access (functioning or not) in regular post-transplant consultation and value any alterations in the attempt of a timely diagnosis. Although rare, angiosarcoma is an important entity that should be considered in the differential diagnosis of soft tissue masses arising from a vascular access, especially in immunocompromised patients. Aggressive treatment should be offered whenever possible.

Renal transplant immunology in the last 20 years: A revolution towards graft and patient survival improvement.

To deride the hope of progress is the ultimate fatuity, the last word in poverty of spirit and meanness of mind. There is no need to be dismayed by the fact that we cannot yet envisage a definitive solution of our problems, a resting-place beyond which we need not try to go. -P.B. Medawar, 1969 * Thomas E. Starlz, also known as the Father of Clinical Transplantation, once said that organ transplantation was the supreme exception to the rule that most major advances in medicine spring from discoveries in basic science [Starzl T. The mystique of organ transplantation. J Am Coll Surg 2005 Aug;201(2):160-170]. In fact, the first successful identical-twin kidney transplantation performed by Murray's team in December 1954 (Murray J et al. Renal homotransplantations in identical twins. Surg Forum 1955;6:432-436) was the example of an upside down translation medicine: Human clinical transplantation began and researchers tried to understand the underlying immune response and how to control the powerful rejection pathways through experimental models. In the last 20 years, we have witnessed an amazing progress in the knowledge of immunological mechanisms regarding alloimmune response and an outstanding evolution on the identification and characterization of major and minor histocompatibility antigens. This review presents an historical and clinical perspective of those important advances in kidney transplantation immunology in the last 20 years, which contributed to the improvement in patients' quality of life and the survival of end-stage renal patients. In spite of these significant progresses, some areas still need substantial progress, such as the definition of non-invasive biomarkers for acute rejection; the continuous reduction of immunosuppression; the extension of graft survival, and finally the achievement of real graft tolerance extended to HLA mismatch donor: recipient pairs.

Saúde Mental de Estudantes de Escolas Médicas com Diferentes Modelos de Ensino / Medical Students’ Mental Health under Different Educational Models

RESUMO Objetivos Avaliar a saúde mental dos estudantes, estratégias defensivas, fontes de estresse e alívio associadas a diferentes processos educacionais. Método Estudo qualitativo e transversal realizado em fevereiro de 2014 por meio de grupos focais e questionário semiestruturado com 78 estudantes do terceiro semestre de duas escolas médicas numa mesma universidade pública: uma com 53 anos, na capital, com modelo de ensino tradicional, e a outra com três anos, no interior,com modelo de Aprendizagem Baseada em Problemas (ABP). Foi realizada análise descritiva dos dados sociodemográficos, psicoemocionais e processo educacional do questionário e análise de conteúdo temática, além de interpretação psicodinâmica dos dados dos grupos focais. Resultados Responderam ao questionário 38 alunos da escola tradicionale 40 daABP, sendo a maioria do sexo masculino (52,6%), com idade 22+2 anos e solteiros (85%). Dois grupos focais com oito alunos de cada escola revelaram motivações, fontes de estresse e de alívio semelhantes entre os alunos, porém sofrimento psíquico menor nos alunos da ABP, que também referiram maior aproximação de seus professores e pactuação das tarefas. Conclusão O processo educacional foi associado a sofrimento psíquico por alunos de ambos os grupos.

ABSTRACT Objectives To evaluate student mental health, defensive strategies, sources of stress, and relief associated with different educational processes. Methods A qualitative and cross-sectional study was carried out in February 2014 through focus groups and semi-structured questionnaireson 78 students in the 3rd semester at two medical schools in the same public university: one with a 53-year history based in the state capital and that uses traditional teaching models, and the other founded only 3 years ago, located in the interior of the state and using Problem Based Learning (PBL). We carried out a descriptive analysis of the dataemergent from the questionnaire andperformed thematic content analysis, along with a psychodynamicinterpretationof data fromfocus groups. Results 38 students from the traditional school and 40 students from the PBL school answered the questionnaire. Most were men(52.6%) aged 22+2years and single(85%). Twofocus groups with8students fromeach schoolrevealedsimilar motivations, sources of stress andreliefamong students, but less psychological distresswas registered inPBLstudents,who reported greatercloseness with teachersand agreementon tasks. Conclusion Educationalprocesseswere associated withpsychological distress amongstudentsin both groups.

Acute liver failure due to primary amyloidosis in a nephrotic syndrome: a swiftly progressive course.

AL amyloidosis is a clonal plasma cell proliferative disorder characterised by extracellular tissue deposits of insoluble fibrils derived from κ or λ immunoglobulin light chains. The most common organs affected by AL amyloidosis are the kidney, presenting with nephrotic syndrome and/or progressive renal dysfunction, and the heart, with restrictive cardiomyopathy. Hepatic deposition of fibrils occurs in half the cases but the liver is rarely the predominantly affected organ. The most common presentation of hepatic amyloidosis is hepatomegaly with elevated alkaline phosphatase. Acute liver failure with cholestasis and jaundice is a rare complication, with a prevalence of approximately 5%, and is usually associated with a worse prognosis. We report a case of a 39-year-old man admitted to our nephrology department with an unusual presentation of primary amyloidosis with nephrotic syndrome and acute liver failure, complicated by obstructive cholestasis resulting in death 2 months after diagnosis.

Severe acute kidney injury and multiple myeloma: evaluation of kidney and patient prognostic factors.

BACKGROUND: Patients with multiple myeloma (MM) manifesting acute kidney injury (AKI) and who later recover renal function and independence from renal replacement therapy (RRT) are considered to have a better outcome. The aim of this work was to study the factors associated with renal function recovery (independence of hemodialysis) and longer survival in these patients. METHODS: A retrospective single center study including patients with a diagnosis of MM and severe AKI, defined as stage 3 of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria: 3.0 times baseline increase in serum creatinine (sCr) or increase in sCr to ≥4.0mg/dL or initiation of RRT, was conducted. Data was registry-based and collected between January 2000 and December 2011. We examined demographic and laboratorial data, presenting clinical features, precipitating factors, need for RRT and chemotherapy. Death was considered the primary endpoint. RESULTS: Lower serum ß2-microglobulin was the only independent factor associated with recovery of renal function and independence of RRT (OR 0.95, 95% CI: 0.91-0.99, P=0.02). The median survival after AKI was 10.7±12.1months. The factors associated with longer survival were independence of RRT (HR 2.21; 95% CI: 1.08-4.49; P=0.02), lower CRP (HR 1.07; 95% CI: 1.03-1.12; P=0.001) and younger age (HR 1.03; 95% CI: 1.01-1.06; P=0.005). CONCLUSIONS: Our study suggests that MM patients with lower serum ß2-microglobulin have a higher likelihood of recovering renal function after severe AKI. Independence of RRT, lower CRP and younger age are associated with longer survival.

The integrated management for renal replacement therapy in Portugal.

Portugal was the first European country to introduce an integrated management of end-stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called "comprehensive price payment." This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009-2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality-driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.

Clinical challenges of an oligosecretory plasma cell dyscrasia.

Light chain deposition disease (LCDD) and immunoglobulin light chain (AL) amyloidosis are uncommon, and heterogeneous clonal plasma cell (PC) proliferative disorders defined by the different biochemical characteristics of the underlying anomalous immunoglobulin. The deposits are usually multisystemic and the two diseases can coexist. The diagnosis is sometimes made difficult by the absence of a detectable paraprotein by routine immunofixation techniques, and the use of serum-free light chain (FLC) immunoassay brought new value in terms of their diagnosis, prognosis and assessment of treatment response. Association of LCDD and AL amyloidosis with multiple myeloma (MM) at the time of diagnosis is common, but further progression to this condition is considered rare. We present a case of a patient diagnosed with systemic LCDD and AL amyloidosis of atypical biochemical characteristics, with no paraprotein detected in immunoelectrophoresis and immunofixation techniques, who progressed to MM in the later course of her disease.

Surgical hepatosplenic mansonic schistosomiasis in adolescents: repercussions of the post-treatment schistosomotic burden on the hepatic functional reserve

Schistosomiasis mansoni affects the hepatic functional reserve. Clinical treatment with oxamniquine is not 100 percent effective and there has been found strain of this parasite resistant to this drug. The aims of this investigation were: (1) to examine the presence of residual parasite burden after medical and surgical treatment on adolescents with surgical schistosomiasis mansoni and (2) to assess the effect on the hepatic functional reserve in patients with and without residual infection. Twenty nine children with hepatosplenic schistosomiasis mansoni and bleeding esophageal varices were treated with oxamniquine. They underwent splenectomy, ligature of the left gastric vein and autologous implantation of spleen tissue into the greater omentum. After a mean post-operative follow up of five years they underwent rectal biopsy for schistosomotic egg search. They were divided in patients with and without infection. In 20 patients the submucosal egg search was negative, however, in 9 it was positive. The hepatic functional reserve in the patients without infection was as follows: 17 were Child-Pugh A and 3 Child-Pugh B. In the patients who were still infected 6 were Child-Pugh A and 3 Child-Pugh B. The chi2 analysis of the hepatic functional reserve showed chi2 = 3.19 - p= 0.07. From the results the following conclusion can be drawn: residual infection or reinfection in the follow up period had not interfered with the distribution of the hepatic functional reserve of the patients in this series. However, there was a trend for a decrease of this parameter in patients with residual infection

Varicocele em jovens portadores de esquistossomose na forma hepatoesplenica cirúrgica / Varicocele in youlth with surgical hepatosplenic schistosomiasis mansoni

Com o objetivo de avaliar o volume testicular e a prevalência de varicolece em jovens portadores de esquistossomose na forma hepatoesplênica associada a varizes sangrentas de esôfago foram selecionados, randomicamente, 24 desses pacientes e avaliados clinicamente e por dopplerfluxometria. Esses pacientes foram submetidos, quando crianças, a esplenectomia, ligadura da veia gástica esquerda e auto-implante de tecido esplênico no omento maior a apresentaram um seguimento médio pós-tratamento, de quatro anos, os achados evidenciaram significativo déficit do desenvolvimento da genitália, alta prevalência de varicocele (66,7por cento)e redução do colume testicular, particularmente do testículo esquerdo

Esquistossomose mansônica hepatoesplênica em adolescentes: carga parasitária residual após tratamento clínico-cirúrgico / Hepatosplenic mansonic schistosomiasis in adolescents: Residual parasitary burden after medical and surgical treatment

A esquistossomose na forma hepatoesplênica associada a varizes sangrentas do esôfago, hiperesplenismo e/ou hipoevolutismo, em adolescentes, tem sido tratada clinicamente com oxamniquime e cirurgicamente por esplenectomia, ligadura da veia gástrica esquerda e auto-implante esplênico. Nos casos de recidiva hemorrágica, os pacientes são incluidos no protocolo de escleroterapia endoscópica das varizes esofageanas. No seguimento pós-operatório desses pacientes tem sido observado a manutenção de hiperglobulinemia G e M, e, eosinnofilia, fazendo supor a possibilidade de manutenção de carga parasitária residual ou reinfecção. vinte e quatro pacientes, entre 11 e 20 anos, foram submetidos a biópsia retal e oograma quantitativo, além do Kato-Katz para verificação dessa possibilidade. Em 17 pacientes, o oograma foi negativo, entretanto, em sete, o exame foi positivo, dos quais, quatro apresentavam ovos viáveis. O Kato-Katz, com ovos viáveis foi igualmente, positivo nesses quatros pacientes. Observou-se associação positiva entre os elevados níveis séricos de imunoglobulina G e a positividade do oograma. Os achados indicam uma carga parasitária residual ou reinfecção em cerca de 17 por cento dos pacientes, o que poderia estar interferindo na evolução clínica desses pacientes