Two-year Experience of the "Organ Donation Week" of the Federal University of Health Sciences of Porto Alegre, Brazil.

BACKGROUND: Today, Brazil is the second country of the world in number of transplants. Nonetheless, waiting lists are getting longer. This lack of organs occurs mostly because of people's reduced knowledge about the donation process. With the aim of changing this scenario, in 2013 and 2014, "Organ Donation Week" events were held at the Federal University of Health Sciences of Porto Alegre. METHODS: During the 2 years, documentaries followed by a cycle of debates with experts in this area were exhibited. In 2013, a "flash-mob" took place, with the purpose of performing a "transplant waiting list" around the perimeter of Santa Casa's Hospital Complex. In 2014, a morning full of educational activities was planned for the pediatric patients from the Santo Antônio Children's Hospital and their relatives. RESULTS: It is estimated that approximately 1774 people were directly reached by the projects. Among these people, we can include medical students, healthcare professionals, university staff, transplanted patients, and their families. We believe that education and consciousness are central points in the donation and transplant process. Through this project, we could inform people about it, solving their doubts and myths and stimulating this kind of conversation among the family circle, making the moment when the family must make the decision much easier. CONCLUSIONS: Education and public awareness are essential for enhancing the number of organ donations. Therefore, events such as "Organ Donation Week" should be encouraged among medical schools.

Implementing Activities Developed by the Organ Transplantation Academic Society of the Hospital Dom Vicente Scherer: A Pilot Study.

BACKGROUND: The number of academic societies has been growing significantly in Brazilian universities, offering an extra opportunity for the development of educational activities and research. Because organ donation and transplantation is an area still insufficiently approached during the graduation of health professionals, we evaluated how academic societies might be a valuable tool. METHODS: Participants of the course promoted by the Organ Transplantation Academic Society of the Hospital Dom Vicente Scherer were evaluated through the use of a questionnaire and cognitive tests with 16 multiple-choice questions about topics approached during the course, before and after the lectures. Topics approached consisted of a general introduction about transplantation in Brazil, brain death, organ allocation and removal, post-transplant follow-up, and clinical cases. RESULTS: Of the 45 participants, 30 answered the tests at both times. The subjects were students of medicine, nursing, and phonoaudiology; 93.3% were organ donors, 84.6% said their families knew about this decision, and 65% had relatives who were organ donors. The mean score of correct answers was 7.63 of 16 before the activities and 12.54 after activities, demonstrating a 64.4% improvement. CONCLUSIONS: The improvement in performance suggests that academic societies are a useful resource for educational purposes and for students to get a deeper insight about organ donation and transplantation.

Radiological impact of natural radionuclides from soils of Salamanca, Mexico.

Salamanca is the centre of a large industrial complex associated with the production and refining of oil-derived products in the state of Guanajuato, Mexico. The city also hosts a large chemical industry, and in past years a major fertilizer industry. All of them followed NORM (naturally occurring radioactive materials) industrial activities, where either raw materials or residues enriched in natural radionuclides are handled or generated, which can have an environmental radiological impact on their environmental compartments (e.g. soils and aquatic systems). In this study, activity concentrations of radionuclides from the 238U and 232Th natural series present in superficial urban soils surrounding an industrial complex in Salamanca, México, have been determined to analyse the possible environmental radiological impact of some of the industrial activities. The alpha-particle and gamma-ray spectrometry is used for the radiometric characterization. The results revealed the presence of 10-42, 11-51 and 178-811Bq/kg of 238U, 232Th and 40K, respectively, without any clear anthropogenic increment in relation to the values normally found in unaffected soils. Thus, the radioactive impact of the industrial activities on the surrounding soils can be evaluated as very low, representing no radiological risk for the health of the population.

What is organ donation and transplantation? Educating through the doubt.

BACKGROUND: Organ transplantation in Brazil is increasing, but one of its current obstacles is the negative response of the population to organ donation. Therefore, to make the process viable, it is essential that people are educated in organ donation and transplantation. The purpose of this research was to evaluate the main doubts on this subject and to clarify these issues by educating the respondents on the basis of their questions. METHODS: Handout questionnaires about organ donation and transplantation were distributed in public schools. The public targets were parents, teachers, and students. The interviewers were trained medical students. RESULTS: In this pilot study with 293 subjects, 97% of respondents had already heard about organ donation; 81% said they would donate their organs, whereas 76% said they would donate the organs of family members and 78% said they believe in the existence of organ trafficking in Brazil. CONCLUSIONS: The high percentage of respondents believing in the existence of an organ trade highlights the urgency in clarifying this topic. To do so, the population must be educated about the ethics of the process of donation, emphasizing the fact that there is no organ trade in Brazil.

Pre-emptive pediatric kidney transplantation or not?

BACKGROUND: Kidney transplantation prior to dialysis (pre-emptive kidney transplantation, PKT) has been controversial because of the paucity of clinical evidence to clarify the risks and benefits of PKT. Several authors have confirmed a significant advantage of PKT in the treatment of patients with end-stage renal disease (ESRD). The aim of this study was to examine the characteristics of patients who received PKT or non-pre-emptive kidney transplant (NPKT). METHODS: We used a cohort of 323 consecutive kidney-transplanted children (53% boys) from Hospital da Criança Santo Antonio, Porto Alegre, Brazil, who underwent transplantation between January 2000 and December 2010. RESULTS: The main causes of ESRD were congenital anomalies of the kidney and urinary tract (CAKUT) (39%) and glomerulopathies (27.5%). The 12-, 36-, 60-, and 90-months death-censored graft survival rates were 97%, 92%, 86%, and 76%, respectively, in the PKT group, and 87%, 79%, 72%, and 65% in the NPKT group (P < .05). CONCLUSIONS: The results of this study suggest that pre-emptive transplantation is beneficial (hazard ratio = 0.37; 95% confidence interval: 0.18-0.82). The main causes of graft loss (n = 67) were recurrence of primary disease (21%), chronic allograft injury (17%), and death with a functioning graft (16%). We recommend PKT as a better choice for transplantation whenever possible to minimize ESRD morbidity and provide better long-term patient and graft survival.

Organ transplants and education: experience of the Universidade Federal de Ciências da Saúde de Porto Alegre with subjects.

INTRODUCTION: Today there is an insufficient number of donated organs in Brazil. This is particularly due to the general population's and health care professionals' lack of information. Therefore, with this project we intend to consolidate knowledge on organ donation to teach health care students of different areas so they are able to propagate such knowledge. MATERIALS AND METHODS: In 2006, at Universidade Federal de Ciências da Saúde de Porto Alegre, an "Organ donation and transplants" subject was created, with the aim to educate health care students. In the next years, it was split in two subjects, named "Introduction to transplants" and "Donation and transplants." By enrolling, students get theoretical classes and practical experience in out- and inpatient facilities and in surgical environments at the Santa Casa Hospital Complex. Furthermore, they can participate in campaigns at parks, stadiums, and health care fairs that take place at several schools in Porto Alegre. To finish the subjects, students present a conclusion report. RESULTS: Seven years after implementation of the subject, and with more than 400 students enrolled, several accomplishments can be highlighted. For example, the creation of the Organ Transplantation League, the implementation of a day to spread conception of the donation-transplant process (with the elaboration of a Web page on the subject), and the release of a book on the subject written by students and professors. DISCUSSION AND CONCLUSION: Health care professionals' education is a central point in donation and transplant process. This is because they become, inevitably, educators, and this brings a long-term consequence, consisting of enhanced logistics skills on brain-death diagnosis and further transfer of information to the population (hopefully reducing denial by families at the time of the donation). We conclude that this is a project to be followed by other medical schools so that, effectively, the number of donors increases and, consequently, the transplantation of organs and tissues as well.

Critical slowing down and noise-induced intermittency in bistable perception: bifurcation analysis.

Stochastic dynamics and critical slowing down were studied experimentally and numerically near the onset of dynamical bistability in visual perception under the influence of noise. Exploring the Necker cube as the essential example of an ambiguous figure, and using its wire contrast as a control parameter, we measured dynamical hysteresis in two coexisting percepts as a function of both the velocity of the parameter change and the background luminance. The bifurcation analysis allowed us to estimate the level of cognitive noise inherent to brain neural cells activity, which induced intermittent switches between different perception states. The results of numerical simulations with a simple energy model are in good qualitative agreement with psychological experiments.

Kidney transplantation in children weighing less than 15 kg: extraperitoneal surgical access-experience with 62 cases.

Small children are a challenging group in whom to perform KT. This retrospective study analyzed the results of 62 KTs in children weighing <15 kg, performed between 1998 and 2010, using extraperitoneal access and anastomosis of the renal vessels of donors to the aorta and IVC or iliac vessels of the recipients. Thirty-two (51.6%) grafts were LRDTs and 30 (48.4%) were DDRTs-28 of them pediatric. The mean age at KT was 3.7 ± 2.2 yr (1-12), and the mean weight was 12.3 ± 2.1 kg (5.6-14.9). Ten children weighed <10 kg, and five (8.1%) children presented previous thrombosis of the venous system. At one and five yr, patient survival was 93.2% and 84.2%, and graft survival was 85.2% and 72.7%. There were no differences between the rates for LRDT and DDRT. There were six vascular complications (four vascular thromboses, one laceration, and one renal artery stenosis) and two perirenal collections. Extraperitoneal access is a valid KT technique in children weighing <15 kg.

Simultaneous pancreas-kidney transplantation: evaluation of graft function, cholesterol, triglycerides, and immunosuppressive regimens.

AIMS: To evaluate pancreas graft function, use of insulin, cholesterol, triglyceride levels, prescription of lipid-lowering drugs, and immunosuppressive regimens among recipients of simultaneous pancreas-kidney transplants (SPKT), who had initial immunosuppression with tacrolimus, sirolimus, and corticosteroids. METHODS: From 2000 to 2007, we performed 73 SKPT, among which we conducted a retrospective data analysis on 51 medical records of patients who had been followed for at least 6 to 72 months. We excluded from the analysis eight recipients who died before 6 months: eight with early pancreas graft losses and six for continued follow-up in other centers. RESULTS: There were four pancreas graft losses after 6 months due in two diabetes mellitus recurrence, one posttuberculosis treatment, and one after use of nonsteroidal inflammatory medication. Mean plasma glucose levels ranged from 84 to 103 mg/dL, while glycosylated hemoglobin (HbA1) levels ranged from 5.7% to 6.2%. At 6, 12, 36, and 60 months, 80%, 91%, 86%, and 75% of recipients, respectively, had HbA1 lower than 6.5%. In the same period, 10%, 8%, 10%, and 11% of recipients became insulin-dependent. Mean cholesterol levels (mg/dL) at 6, 12, 36, and 60 month were 190, 180, 196 and 193, while triglyceride levels (mg/dL) were 162, 129, 106, and 113 respectively. Recipient's rate of lipid-lowering drug use was 18%, 21%, 20%, and 22% at 6, 12, 36, and 60 months. Mean serum creatinine levels (mg/dL) with standard deviations were 1.3 +/- 0.4, 1.5 +/- 0.4, 1.6 +/- 0.5, 1.8 +/- 0.9, at 6, 12, 36 and 60 months respectively. Nineteen recipients had sirolimus suspended and 14 recipients, tacrolimus suspended as well for various reasons. CONCLUSION: Mean plasma glucose levels were normal during the period. About 10% of recipients became insulin-dependent and 20% required lipid-lowering drugs. The immunosuppressive regimen protocol had to be changed in 60% of patients.

[Efficacy and safety of intravitreal injection of bevacizumab in the treatment of neovascular glaucoma: systematic review]. / Eficacia y seguridad de la inyección intravítrea de bevacizumab en el tratamiento del glaucoma neovascular: revisión sistemática.

PURPOSE: Systematic review on efficacy and safety of intravitreal bevacizumab (IVB) in the treatment of neovascular glaucoma (NVG). All original papers published in Medline (prior to August 2008) were included. METHODS: Search and selection of information on the internet and in Medline, validated by Kappa Index (K). Statistical and clinical study of the results in the selected articles on a one by one basis. RESULTS: 26 original papers analyzed the efficacy and safety of the procedure in case reports and short series of cases (127 eyes). The efficacy calculated in the sample was 68.7% and the recurrence rate was 18.6% in 4.2 months of follow-up. All studies were after 2006 and none of them was a clinical randomized controlled assay. Ophthalmic complications were under 0.78% and no systemic complications were found. CONCLUSIONS: The use of bevacizumab demonstrates that intravitreal injections may be effective and useful to manipulate growth factors in the anterior chamber. IVB could serve as a first line treatment for NVG. Clinical trials are needed to confirm these results before its use is authorized.

Follow-up of kidney donors who developed uremia and went on the waiting list for a transplant: should they have allocation priority?

BACKGROUND: The increasing use of living kidney donors requires knowledge about long-term effects, especially number and causes of donors with chronic renal failure (CRF), and discussion about a regular follow-up program for donors, policies giving priority to kidney donors on the waiting list for a kidney, and a national record of donors. METHODS: We performed a Retrospective analysis of 470 records of our kidney donors from the kidney transplantation unit between 1977 and 1997. RESULTS: Five out of the 470 donors developed CRF (1.1%), with a calculated incidence of 610 per million people a year. CONCLUSION: The data showed that the risk of a donor developing CRF may be higher than in the in general population. These results showed the necessity of creating an effective follow-up program for donors and a national record.

Educational program of organ donation and transplantation at medical school.

A favorable attitude of health professionals to organ donation can positively influence the decision of families of potential donors. By increasing health professionals knowledge about donation and transplantation and qualifying them to disseminate information, education has produced a positive response to increase the insufficient number of donors. Educating students early in their careers may become crucial in this setting. In order to supply the necessary information about the process of donation and transplantation, a medical school in association with the Hospital Transplant Coordination Department created an educational program of organ donation and transplantation. This course is intended for medical, biomedical, and nutrition students. The objective of our program is to supply basic knowledge about organ donation and transplantation to students of medicine, nutrition, and biomedicine and to enhance their commitment to this process. Each semester, 50 to 90 students are enrolled in the course, which involves a total of 25 hours. Various aspects are approached such as brain death, donor management, political and legal aspects of donation, and skin, lung, bone marrow, heart, pancreas, liver, and kidney transplantation. Between March 2006 and June 2007, three courses were carried out and 200 students were trained. The students evaluated the course and rated it as excellent, concluding that it contributed to their education. Their attitude toward organ donation and transplantation was strongly positive at the end of the course. This project aims to educate and stimulate students in the process of organ donation and transplantation and should be implemented in other medical schools.

Project of cornea donation in the hospital complex of Santa Casa de Porto Alegre, Brazil.

Rio Grande do Sul is a state of 10 million inhabitants, with 800 patients on the transplantation waiting list (80 per million population [pmp]/y) with a mean waiting time of 2 years. Up to 2000, there were 11 to 15 cornea donors and 70 to 80 transplantations yearly. Seeking to increase the number of corneas available for transplantation and reduce the time on the waiting list, we initiated a project wherein the hospital transplantation coordinator trained the morgue staff to evaluate all deceased persons. If the person had no contraindication, the morgue staff called the coordinator to interview the family. Whenever donation was authorized, the coordinator communicated with the Cornea Bank to perform a removal. There was a major increase in the number of donations (220/y) with this project responsible for more than 70% of the cornea donors on cardiac arrest in the Rio Grande do Sul State. The mean time on the waiting list decreased to 14 months. This model was efficient, and must be implemented in other hospitals in the state, attempting to decrease both the list and the waiting time for a corneal transplant.

Organ donation in suicides.

INTRODUCTION: There are few reports in the literature analyzing brain death epidemiology in suicides, or the rate of donation and family authorization in such situations. OBJECTIVE: The objectives of this study were to analyze the frequency of suicide as a cause of brain death and to compare the donation rates among this population with other causes of brain death. PATIENTS AND METHODS: We reviewed records from 2627 potential donors between 1988 and 2004. RESULTS: Within that period, 101 (3.8%) cases of brain death were recorded as suicides. The mean age was significantly lower (P < .05) in cases of suicide than for other causes (26.2 + 11.1 vs 34.4 + 16.5 years); there was a male prevalence (76.2% vs 60.8%). As to suicides, the donation rate was significantly higher than in other situations (62.3% vs 43.8%). This was due to a lower rate of negative family responses (17.8% vs 32.1%). CONCLUSIONS: Suicide is a frequent cause of brain death (3.8%), mainly among young men. The donation rate in this group is higher than that due to other causes of death because of a lower negative response rate by the family. The explanation remains to be clarified for such a low refusal rate for organ donation by the relatives of potential donors due to suicide.

Renal transplantation in children younger than 6 years old.

Herein we report our experience in renal transplantation in 38 children (40 transplants), ages 1 to 5 years, between 1989 and 2005. Demographics as well as patient and graft survivals are reported. Mean age at transplantation was 3.3 +/- 1.3 years, and mean weight was 14 kg (range, 5.7-25 kg); 92.5% were Caucasian, 7.5% African-Brazilian. The main etiology for end-stage renal disease (ESRD) was uropathic/vesicoureteral reflux (45%) followed by glomerulopathy (25%), congenital/hereditary diseases (10%), and hemolytic uremic syndrome (12.5%). Prior to transplantation, 5% were on hemodialysis, 85% on peritoneal dialysis, and 10% preemptive. All children were followed for at least 6 months posttransplantation, except 2 who died in the first month. In 75% of cases, kidneys were obtained from living-related donors, and in 25% from deceased donors. Thirty-nine kidneys were extraperitoneally placed. Primary immunosuppressant therapy consisted of cyclosporine (61%), tacrolimus (39%), mycophenolate (49%), and azathioprine (51%). A steroid-free protocol was used in 17% of patients. In the last 21 cases, basiliximab or daclizumab was added. There were 13 (32.5%) graft losses (4 artery/vein thromboses, 3 chronic rejections, 3 deaths, 3 other causes). The 5-year patient and graft survival rates were 89.6% and 72.2%. We have concluded that renal transplantation can be performed with good long-term results in children younger than 6 years old.

300 pediatric renal transplantations: A single-center experience.

UNLABELLED: Our objective was to relate the results of 300 consecutive kidney transplants performed in children at a single center. PATIENTS AND METHODS: An analysis of kidney transplants was performed on patients less than 18 years old engrafted from May 1977 to August 2005. RESULTS: Among 300 kidney transplants, 48% of the patients were female, 87% were Caucasian, and 13% were African-Brazilian. The mean age at transplant was 11.5 +/- 4.5 years with 39 (13%) less than 6 years of age. The most frequent etiology of renal failure was vesicoureteral reflux/obstructive uropathy (36%) followed by glomerulopathy (27%). The donor was deceased in 32.3% and living related in 77.7% (parents 82%). The mean posttransplant follow-up was 4.8 +/- 4.3 years. The initial immunosuppression was CyA + AZA + PRED in 45%; CyA + MMF + PRED in 9.6%; TAC + AZA + PRED in 7.3%; TAC + MF + PRED in 9.7%; or TAC + MF without PRED in 10%. Sirolimus was employed initially in three cases. Induction with OKT3/ATG occurred in three patients and 112 received an anti-IL2 receptor antibody. The 103 graft losses during 28 years of follow-up were secondary to chronic allograft nephropathy in 51 (49.5%), vascular thrombosis in 5 (4.8%), acute rejection in 12 (11.6%), and recurrence of original disease in 13 (12.6%). Sixteen (15.5%) died with functioning grafts. Graft survival in the first, fifth, and tenth year were 90%, 72%, and 59%, respectively. Patient survival in the first, fifth, and tenth years were 95%, 93%, and 85%, respectively, with infection as the main cause of death.

Conversion to sirolimus in pediatric renal transplantation recipients.

We retrospectively evaluated the efficacy and safety of sirolimus (SRL) in 16 pediatric renal transplant recipients, who were 9.4 +/- 4.1 years of age when they first received SRL. The indications for SRL therapy were rescue from steroid-resistant acute rejection (31.3%), neoplasia (31.3%), diabetes (12.5%), polyomavirus-associated nephropathy (6.3%), chronic allograft dysfunction (6.3%), calcineurin inhibitor nephrotoxicity (6.3%), and hemolytic uremic syndrome (6.3%). Mean follow-up after the switch to SRL was 17.7 +/- 15 months. The final immunosuppression was CNI + SRL + prednisone (PRED) in five patients, SRL + PRED in six, SRL + mycophenolate mofetil (MMF) + PRED in four, and SRL + MMF in one. The use of SRL in these selected pediatric renal recipients was successful, except when creatinine was high at the moment of conversion. Further studies are necessary to assess the beneficial outcomes versus adverse events among the pediatric transplant population receiving SRL for immunosuppression.

Plasmapheresis for recurrent posttransplant focal segmental glomerulosclerosis.

The high recurrence rate of focal segmental glomerulosclerosis (FSGS) in kidney transplant recipients suggests that such patients have a circulating factor that alters glomerular capillary permeability. Serum from patients with FSGS increases glomerular permeability to albumin. This permeability factor has been partially identified as a protein. The removal of this protein by plasmapheresis (PP) decreases proteinuria. In this study we report data on the therapeutic effects of PP in FSGS children with recurrence in the transplanted kidney. Three hundred pediatric (age <19 years) renal transplants were performed, including 21 patients (24 transplants) with FSGS as a cause of renal failure. Fourteen (58.3%) subjects experienced disease recurrence (proteinuria >1 g/m(2) per day) within 1 month after transplantation. Mean age patient was 12 +/- 4.3 years, including 83.3% Caucasians and 70.2% recipients of living donor grafts. Nine were treated with 10 cycles of PP (3 cycles/weekly), initiated immediately after recurrence (<48 hours). Immunosuppression included high doses of cyclosporine (C(2) levels of 1700-1800 ng/mL), mycophenolate sodium or mofetil, and prednisone. Thirteen patients were induced with anti-IL2 receptor monoclonal antibody (daclizumab/basiliximab). Among the patients who underwent PP, five (55.5%) achieved a complete remission and one (12%), a partial remission (1 g/24 hours). There were no cases of remission among the five patients who were not treated with PP. Those who achieved remission after PP experienced no recurrences during the 2.6 +/- 1.4 years follow-up. PP appears to be effective to treat recurrent FSGS following kidney transplantation. It should be started as soon as possible.

Expanding criteria for the use of living donors: what are the limits?

The cadaver organ shortage has pushed the transplant community to extend the boundaries beyond the traditional criteria used for living donor transplantation. This new liberal policy involves: (1) the type of donor, such as emotionally related individuals, the direct or indirect interchange of donors, anonymous as well as rewarded donation; (2) challenging immunological criteria, using incompatible ABO blood types and or transplantation across a positive cross-match; (3) relaxing clinical criteria related to elderly, hypertensive, or obese donors, or patients with nephrolithiasis, fibromuscular renal artery disease, hematuria, or renal cell carcinomas. However, these practices may be dangerous. They must be clearly validated to promote a liberal policy of donor acceptance since it may carry a risk for both the donor and the recipient as well as for society. It is crucial to ensure the physical integrity of the donor as well as to provide guarantees, for instance a 1-year policy of life insurance, an indefinite long-term medical follow-up and the assurance of going to the top of the waiting list if the donor becomes uremic in the future.