RESUMO
We compare the outcomes of induction therapies with either methylprednisolone (group 1, n = 58), basiliximab (group 2, n = 56) or alemtuzumab (group 3, n = 98) in primary deceased donor kidney transplants with delayed graft function (DGF). Protocol biopsies were performed. Maintenance was tacrolimus and mycophenolate with steroid (group 1 and 2) or without steroid (group 3). One-year biopsy-confirmed acute rejection (AR) rates were 27.6, 19.6 and 10.2 % in group 1, 2 and 3 (p = 0.007). AR was significantly lower in group 3 (p = 0.002) and group 2 (p = 0.03) than in group 1. One-year graft survival rates were 90, 96 and 100 % in group 1, 2 and 3 (log rank p = 0.006). Group 1 had inferior graft survival than group 2 (p = 0.03) and group 3 (p = 0.002). The patient survival rates were not different (96.6, 98.2 and 100 %, log rank p = 0.81). Multivariable analysis using methylprednisolone induction as control indicated that alemtuzumab (OR 0.31, 95 % CI 0.11-0.82; p = 0.03) and basiliximab (OR 0.60, 95 % CI 0.23-0.98; p = 0.018) were associated with lower risk of AR. Therefore, alemtuzumab or basiliximab induction decreases AR and improves graft survival than methylprednisolone alone in patients with DGF. Alemtuzumab induction might also allow patients with DGF to be maintained with contemporary steroid-withdrawal protocol.
Assuntos
Anticorpos Monoclonais Humanizados/administração & dosagem , Anticorpos Monoclonais/administração & dosagem , Função Retardada do Enxerto/tratamento farmacológico , Imunossupressores/administração & dosagem , Quimioterapia de Indução/métodos , Transplante de Rim/efeitos adversos , Rim/efeitos dos fármacos , Metilprednisolona/administração & dosagem , Proteínas Recombinantes de Fusão/administração & dosagem , Adulto , Alemtuzumab , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais Humanizados/efeitos adversos , Basiliximab , Distribuição de Qui-Quadrado , Função Retardada do Enxerto/diagnóstico , Função Retardada do Enxerto/imunologia , Função Retardada do Enxerto/fisiopatologia , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Humanos , Imunossupressores/efeitos adversos , Quimioterapia de Indução/efeitos adversos , Estimativa de Kaplan-Meier , Rim/imunologia , Rim/fisiopatologia , Modelos Logísticos , Masculino , Metilprednisolona/efeitos adversos , Pessoa de Meia-Idade , Análise Multivariada , Proteínas Recombinantes de Fusão/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Sustained low efficiency dialysis (SLED) involves the use of standard dialysis machines for prolonged intermittent renal replacement therapy in critically ill patients. In this study we aimed to quantify dialysate amino acid (AA) and albumin losses in 5 patients who underwent successful SLED treatment. DESIGN: This was a prospective observational study. SETTING: The study was performed in a general intensive care unit. SUBJECTS: The study was performed in critically ill patients with acute kidney injury undergoing SLED using low-flux hemodialyzers. INTERVENTION: We performed total dialysate collection and measured dialysate AA profiles by reverse phase high-pressure liquid chromatography using an automated AA analyser. MAIN OUTCOME MEASURE: Individual and total amino acid losses. RESULTS: Albumin was undetectable in dialysate. The median (mean ± SD) total amino acid loss was 15.7 (23.4 ± 19.2) g/treatment, or 122.1 (180.6 ± 148.5) mmol/treatment. Two patients were receiving intravenous nutrition. One patient had severe hepatic failure with encephalopathy, and had high dialysate AA levels with a total loss of 57 g/treatment. CONCLUSIONS: During SLED with low-flux hemodialyzers, albumin losses are negligible but AA losses to dialysate are comparable to those during continuous renal replacement therapy. Patients' nutritional protein prescriptions should be augmented to account for this.