RESUMO
Iron deficiency contributes to anemia after transplantation. The magnitude of iron loss from blood loss in the peri-transplantation period has not been quantified. We prospectively estimated phlebotomy and surgical losses over the first 12-weeks following transplantation in 39 consecutive renal transplant recipients on hemodialysis (HD), peritoneal dialysis (PD), or chronic kidney disease (CKD). At transplant, ferritin levels were <200 ng/ml in 51% of the patients, and iron saturation was =20% in 44%. CKD patients more commonly had ferritin levels <200 ng/ml than either HD or PD patients (100% vs. 21% vs. 67%, P < 0.0002, respectively). Blood loss was similar among HD, PD and CKD patients (833 +/- 194 vs. 861 +/- 324 vs. 755 +/- 79 ml respectively, P = NS), and no difference between deceased and living donor transplant recipients (881 +/- 291 vs. 788 +/- 162 ml, P = 0.33). Based on baseline hemoglobin (Hgb) of 11.8 g/dl, we estimated that an additional 330 mg of iron was needed to normalize hemoglobin to 13 g/dl, and 605 mg to increase hemoglobin to 14 g/dl. Blood and iron losses over the first 12 weeks post-transplant are substantial and may warrant early administration of intravenous iron.
Assuntos
Anemia Ferropriva/etiologia , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Hemoglobinas/metabolismo , Ferro/metabolismo , Transplante de Rim/efeitos adversos , Adulto , Idoso , Antivirais/uso terapêutico , Feminino , Ferritinas/sangue , Ganciclovir/análogos & derivados , Ganciclovir/uso terapêutico , Humanos , Terapia de Imunossupressão , Infusões Intravenosas , Ferro/administração & dosagem , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Valganciclovir , Adulto JovemRESUMO
BACKGROUND: Use of induction for renal transplantation is controversial because of the concerns about long-term safety and efficacy. METHODS: We compared the safety and efficacy at 10 years among patients randomized to thymoglobulin or Atgam induction in a single center, randomized, double-blinded trial. Quality-adjusted life years (QALYs) were calculated using utility weights. RESULTS: The primary composite endpoint of freedom from death, graft loss, or rejection, "event-free survival," was higher with thymoglobulin compared with Atgam (48% vs. 29%; P=0.011). At 10 years, patient survival (75% vs. 67%) and graft survival (48% vs. 50%) were similar, whereas acute rejection remained lower (11% vs. 42%, P=0.004) in the thymoglobulin group. The incidence of all types of cancer was numerically lower with thymoglobulin compared with Atgam (8% vs. 21%, P=NS). There were no posttransplant lymphoproliferative disorder in the thymoglobulin group and there were two cases in the Atgam group. There were no new cases of cytomegalovirus disease in either group. Mean serum creatinine levels were higher (1.7+/-0.5 mg/dL vs. 1.2+/-0.3 mg/dL; P=0.003) and estimated glomerular filtration rates tended to be lower (49+/-22 mL/min vs. 65+/-19 mL/min; P=0.065) in the thymoglobulin group. There were 0.53 QALYs gained (3.68 thymoglobulin vs. 3.15 Atgam; 16.7% improvement) from thymoglobulin compared with Atgam. CONCLUSIONS: This long-term follow-up showed that thymoglobulin was associated with higher event-free survival and improved QALYs, without increased posttransplant lymphoproliferative disorder or cytomegalovirus disease, compared with Atgam at 10 years.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Soro Antilinfocitário/uso terapêutico , Terapia de Imunossupressão/métodos , Transplante de Rim/fisiologia , Adulto , Intervalo Livre de Doença , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto/fisiologia , Humanos , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , SegurançaAssuntos
Imunossupressores/efeitos adversos , Transplante de Rim , Edema Macular/induzido quimicamente , Edema Macular/fisiopatologia , Propilenoglicóis/efeitos adversos , Esfingosina/análogos & derivados , Ciclosporina/uso terapêutico , Quimioterapia Combinada , Cloridrato de Fingolimode , Angiofluoresceinografia , Rejeição de Enxerto/prevenção & controle , Humanos , Falência Renal Crônica/cirurgia , Edema Macular/diagnóstico , Prednisona/uso terapêutico , Esfingosina/efeitos adversos , Tomografia de Coerência Óptica , Transplante HomólogoRESUMO
Our purposes were to determine the incidence of BK viruria, viremia or nephropathy with tacrolimus (FK506) versus cyclosporine (CyA) and whether intensive monitoring and discontinuation of mycophenolate (MMF) or azathioprine (AZA), upon detection of BK viremia, could prevent BK nephropathy. We randomized 200 adult renal transplant recipients to FK506 (n = 134) or CyA (n = 66). Urine and blood were collected weekly for 16 weeks and at months 5, 6, 9 and 12 and analyzed for BK by polymerase chain reaction (PCR). By 1 year, 70 patients (35%) developed viruria and 23 (11.5%) viremia; neither were affected independently by FK506, CyA, MMF or AZA. Viruria was highest with FK506-MMF (46%) and lowest with CyA-MMF (13%), p = 0.005. Viruria >/= 9.5 log(10) copies/mL was associated with a 3-fold increased risk of viremia and a 13-fold increased risk of sustained viremia. After reduction of immunosuppression, viremia resolved in 95%, without increased acute rejection, allograft dysfunction or graft loss. No BK nephropathy was observed. Choice of calcineurin inhibitor or adjuvant immunosuppression, independently, did not affect BK viruria or viremia. Viruria was highest with FK506-MMF and lowest with CyA-MMF. Monitoring and preemptive withdrawal of immunosuppression were associated with resolution of viremia and absence of BK nephropathy without acute rejection or graft loss.