RESUMO
AIM: The aim of this work is to examine the effectiveness of a psychoeducational intervention on self-efficacy (primary outcome), anxiety, depression, treatment adherence, and health-related quality of life (HRQoL) of patients undergoing haemodialysis. METHODS: A two-group randomized controlled trial of 124 patients (65 and 59 patients in the intervention and control groups, respectively) recruited from a tertiary hospital in Singapore was conducted. Data were collected from January 2015 to June 2016. Outcomes were measured at baseline and 1, 3, and 6 months after the intervention. General linear model was used to analyse data. RESULTS: Our findings showed significant group effect on HRQoL (effects of kidney disease on daily life; p = 0.041), time effect on all outcomes (p < 0.05; except for treatment adherence behaviours and HRQoL [burden of kidney disease]), and group * time interaction effect on anxiety (p = 0.040) and depression (p = 0.003), with the intervention group reporting better outcomes. CONCLUSIONS: The positive effects of our intervention on patients' self-efficacy, psychological well-being, treatment adherence attitudes, and HRQoL implied its potential use in dialysis/renal centres to improve patients' self-care and health outcomes.
Assuntos
Nefropatias , Falência Renal Crônica , Humanos , Falência Renal Crônica/terapia , Qualidade de Vida , Diálise Renal/psicologia , Avaliação de Resultados em Cuidados de SaúdeRESUMO
AIM: The COVID-19 pandemic poses unprecedented operational challenges to nephrology divisions in every country as they cope with COVID-19-related kidney disease in addition to regular patient care. Although general approaches have been proposed, there is a lack of practical guidance for nephrology division response in a hospital facing a surge of cases. Here, we describe the specific measures that our division has taken in the hope that our experience in Singapore may be helpful to others. METHODS: Descriptive narrative. RESULTS: A compilation of operational responses to the COVID-19 pandemic taken by a nephrology division at a Singapore university hospital. CONCLUSION: Nephrology operational readiness for COVID-19 requires a clinical mindset shift from usual standard of care to a crisis exigency model that targets best outcomes for available resources. Rapid multi-disciplinary efforts that evolve flexibly with the local dynamics of the outbreak are required.
Assuntos
Defesa Civil , Infecções por Coronavirus , Procedimentos Clínicos/tendências , Prática de Grupo , Nefropatias , Pandemias , Pneumonia Viral , Insuficiência Renal Crônica , Betacoronavirus , COVID-19 , Defesa Civil/normas , Defesa Civil/estatística & dados numéricos , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/fisiopatologia , Infecções por Coronavirus/terapia , Prática de Grupo/organização & administração , Prática de Grupo/tendências , Hospitais Universitários , Humanos , Comunicação Interdisciplinar , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Nefropatias/virologia , Nefrologia/tendências , Inovação Organizacional , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/organização & administração , Pneumonia Viral/epidemiologia , Pneumonia Viral/fisiopatologia , Pneumonia Viral/terapia , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , SARS-CoV-2 , Singapura/epidemiologiaRESUMO
BACKGROUND: Chronic Kidney Disease (CKD) is a major public health problem worldwide. There is limited literature on a model to project the number of people with CKD. This study projects the number of residents with CKD in Singapore by 2035 using a Markov model. METHODS: A Markov model with nine mutually exclusive health states was developed according to the clinical course of CKD, based on a discrete time interval of 1 year. The model simulated the transition of cohorts across different health states from 2007 to 2035 using prevalence, incidence, mortality, disease transition, and disease detection rates. RESULTS: From 2007 to 2035, the number of residents with CKD is projected to increase from 316,521 to 887,870 and the prevalence from 12.2% to 24.3%. Patients with CKD stages 1-2 constituted the largest proportion. The proportion of undiagnosed cases will decline from 72.1% to 56.4%, resulting from faster progression to higher CKD stages and its eventual detection. CONCLUSION: By 2035, about one-quarter of the Singapore residents are expected to have CKD. National policies need to focus on primary disease prevention and early disease detection to avoid delayed treatment of CKD which eventually leads to end-stage renal disease.
Assuntos
Ergotamina/efeitos adversos , Infarto/induzido quimicamente , Rim/irrigação sanguínea , Vasoconstritores/efeitos adversos , Ergotamina/uso terapêutico , Humanos , Infarto/diagnóstico por imagem , Rim/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/tratamento farmacológico , Medicamentos sem Prescrição/efeitos adversos , Medicamentos sem Prescrição/uso terapêutico , Tomografia Computadorizada por Raios X , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: Previous studies have shown that kidney volume enhances the estimation of glomerular filtration rate (eGFR) in kidney donors. This study aimed to describe the phenomenon of compensatory hypertrophy after donor nephrectomy as measured on computerized tomographic (CT) scans. METHODS: An institutional Domain Specific Review Board (DSRB)-approved study involved approaching kidney donors to have a follow up CT scan from 6 months to 1 year after surgery; 29 patients participated; 55% were female. Clinical chart review was performed, and the patient's remaining kidney volume was measured before and after surgery based on CT scans. eGFR was determined with the use of the Modification of Diet in Renal Disease equation. RESULTS: Mean parenchymal volume of the remaining kidney for this population (mean age, 44.3 ± 8.5 y) was 204.7 ± 82.5 cc before surgery and 250.5 ± 113.3 cc after donor nephrectomy. Compensatory hypertrophy occurred in 79.3% of patients (n = 23). Mean increase in remaining kidney volume was 22.4 ± 23.2% after donor nephrectomy in healthy individuals. Over a median follow-up of 52.9 ± 19.8 months, mean eGFR was 68.9 ± 12.4 mL/min/1.73 m(2), with 24.1% of patients (n = 7) in chronic kidney disease grade 3. Absolute and relative change in kidney volume was not associated with sex, race, surgical approach, or background of hypertension (P = NS). There was a trend of decreased hypertrophy with increasing age (P = .5; Spearman correlation, -0.12). CONCLUSIONS: In healthy kidney donors, compensatory hypertrophy of the remaining kidney occurs in 79.3% of the patients, with an average increment of about 22.4%. Older patients may have a blunted compensatory hypertrophy response after surgery.
Assuntos
Hipertrofia/diagnóstico por imagem , Doadores Vivos , Nefrectomia/efeitos adversos , Coleta de Tecidos e Órgãos/efeitos adversos , Tomografia Computadorizada por Raios X/métodos , Adaptação Fisiológica/fisiologia , Adulto , Fatores Etários , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertrofia/etiologia , Rim/diagnóstico por imagem , Rim/fisiopatologia , Neoplasias Renais/cirurgia , Transplante de Rim/métodos , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Insuficiência Renal Crônica/cirurgia , Estudos Retrospectivos , Coleta de Tecidos e Órgãos/métodosRESUMO
BACKGROUND: Living donor transplantation (LDT) using kidneys with multiple arteries (MA) has previously been reported to be associated with increased complications and poorer outcomes in recipients. The objective of this study was to investigate outcomes of LDT with MA at the National University Hospital of Singapore, an institution with modest kidney transplant volumes. METHODS: From 2007 to 2014, a total of 109 consecutive living donor kidney transplantations were performed. Of the nephrectomies, 91% were left sided. A total of 19 cases involved MA, of which 7 with small polar vessels (<2 mm) were ligated and 12 were revascularized. Baseline characteristics and outcomes were comparable between donor-recipient pairs with MA and single artery (SA). Both groups had equivalent induction and maintenance immunosuppressive regimens. RESULTS: Mean warm ischemia time (minutes) was similar for kidneys with MA and SA (4.3 ± 3.2 vs 3.9 ± 3.2, P = .38). Operative time (minutes) in the recipients was also equivalent (P > .05) for MA and SA (158 ± 39.2 and 145 ± 57.2, respectively). The MA kidney recipients had a lower estimated glomerular filtration rate (eGFR) on postoperative day 5 compared to SA (56.6 ± 24.2 vs 74.1 ± 35.9 mL/min/1.73 m(2), P = .058). However, eGFR at 1 year was the similar for both groups (64.9 ± 16.2 vs 66.4 ± 18.1 mL/min/1.73 m(2), respectively, P = .76). Delayed graft function rates were 5.6% and 6.6% for MA and SA, respectively (P = .9). There were no surgical complications for LDT recipients within the MA group. Patient and graft survival was 100% in the MA group compared with 98% in the SA group (P > .05). CONCLUSIONS: With current surgical techniques, LDT with MA can achieve equally good functional outcomes at 1 year as SA kidneys, with minimal surgical complications.
Assuntos
Transplante de Rim , Rim/irrigação sanguínea , Doadores Vivos , Artéria Renal/transplante , Adulto , Feminino , Taxa de Filtração Glomerular , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos RetrospectivosRESUMO
BACKGROUND: Studies comparing patient survival of hemodialysis (HD) and peritoneal dialysis (PD) have yielded conflicting results and no such study was from South-East Asia. This study aimed to compare the survival outcomes of patients with end-stage renal disease (ESRD) who started dialysis with HD and PD in Singapore. METHODS: Survival data for a maximum of 5 years from a single-center cohort of 871 ESRD patients starting dialysis with HD (n = 641) or PD (n = 230) from 2005-2010 was analyzed using the flexible Royston-Parmar (RP) model. The model was also applied to a subsample of 225 propensity-score-matched patient pairs and subgroups defined by age, diabetes mellitus, and cardiovascular disease. RESULTS: After adjusting for the effect of socio-demographic and clinical characteristics, the risk of death was higher in patients initiating dialysis with PD than those initiating dialysis with HD (hazard ratio [HR]: 2.08; 95% confidence interval [CI]: 1.67-2.59; p<0.001), although there was no significant difference in mortality between the two modalities in the first 12 months of treatment. Consistently, in the matched subsample, patients starting PD had a higher risk of death than those starting HD (HR: 1.73, 95% CI: 1.30-2.28, p<0.001). Subgroup analysis showed that PD may be similar to or better than HD in survival outcomes among young patients (≤65 years old) without diabetes or cardiovascular disease. CONCLUSION: ESRD patients who initiated dialysis with HD experienced better survival outcomes than those who initiated dialysis with PD in Singapore, although survival outcomes may not differ between the two dialysis modalities in young and healthier patients. These findings are potentially confounded by selection bias, as patients were not randomized to the two dialysis modalities in this cohort study.
Assuntos
Falência Renal Crônica/terapia , Diálise Peritoneal , Diálise Renal , Idoso , Sudeste Asiático/epidemiologia , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Resultado do TratamentoRESUMO
BACKGROUND: This study aimed to identify factors associated with the health-related quality of life (HRQOL) of multiethnic Asian end-stage renal disease (ESRD) patients treated with dialysis. The role of dialysis modality was also explored. METHODS: Data used in this study were from two cross-sectional surveys of Singaporean ESRD patients on haemodialysis (HD) or peritoneal dialysis (PD). In both surveys, participants were assessed using the kidney disease quality of life (KDQOL) instrument and questions assessing socio-demographic characteristics. Clinical data including co-morbidity (measured by Charlson comorbidity index [CCI]), albumin level, haemoglobin level, and dialysis-related variables (e.g. dialysis vintage and dialysis adequacy) were retrieved from medical records. The 36-item KDQOL (KDQOL-36) was used to generate three summary scores (physical component summary [PCS], mental component summary [MCS] and kidney disease component summary [KDCS]) and two health utility scores (Short Form 6-dimension [SF-6D] and EuroQol 5-dimension [EQ-5D]). Linear regression analysis was performed to examine the association of factors with each of the HRQOL scale scores. RESULTS: Five hundred and two patients were included in the study (mean age 57.1 years; male 52.4 %; HD 236, PD 266). Mean [standard deviation (SD)] PCS, MCS and KDCS scores were 37.9 (9.7), 46.4 (10.8) and 57.6 (18.1), respectively. Mean (SD) health utility score was 0.66 (0.12) for SF-6D and 0.60 (0.21) for EQ-5D. In multivariate regression analysis, factors found to be significantly associated with better HRQOL included: young (<45 years) or old age (>60 years), low CCI (<5), high albumin (≥37 g/l) and high haemoglobin (≥11 g/dl) with PCS; long dialysis vintage (≥3.5 years) with MCS; old age, Malay ethnicity and PD modality with KDCS; low CCI, high albumin and high haemoglobin with EQ-5D and high albumin with SF-6D. CONCLUSIONS: Clinical characteristics are better predictors of HRQOL in ESRD patients than socio-demographics in Singapore. Dialysis modality has no impact on the health utility of those patients.
Assuntos
Falência Renal Crônica/psicologia , Diálise Peritoneal/psicologia , Qualidade de Vida/psicologia , Diálise Renal/psicologia , Adulto , Idoso , Povo Asiático , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , SingapuraRESUMO
OBJECTIVES: The objective of this study was to compare the performance of the 5-level EuroQol 5-dimension (EQ-5D-5L) and the Short Form 6-dimension (SF-6D) instruments in assessing patients with end-stage renal disease (ESRD) in Singapore. METHODS: In a cross-sectional study, ESRD patients attending a tertiary hospital were interviewed using a battery of questionnaires including the EQ-5D-5L, the kidney disease quality of life instrument (KDQOL-36), and questions assessing dialysis history and socio-demographic characteristics. We reviewed patients' medical records for their clinical information. We assessed the construct validity of the EQ-5D-5L and SF-6D index scores and compared their ability to distinguish between patients differing in health status and the magnitude of between-group difference they quantified. RESULTS: One hundred and fifty ESRD patients on dialysis (mean age, 60.1 years; female, 48.7%) participated in the study. Both EQ-5D-5L and SF-6D demonstrated satisfactory known-groups validity; the EQ-5D-5L was more sensitive to differences in clinical outcomes and the SF-6D was more sensitive to differences in health outcomes measured by KDQOL scales. The intraclass correlation coefficient between the measures was 0.36. The differences in the EQ-5D-5L index score for patients in better and worse health status were greater than those measured by the SF-6D index score. CONCLUSIONS: Both EQ-5D-5L and SF-6D are valid instruments for assessing ESRD patients. However, the two preference-based measures cannot be used interchangeably and it appears that EQ-5D-5L would lead to more favorable cost-effectiveness results than SF-6D if they are used in economic evaluations of interventions for ESRD.
Assuntos
Nível de Saúde , Falência Renal Crônica/fisiopatologia , Preferência do Paciente , Qualidade de Vida , Inquéritos e Questionários/normas , Estudos Transversais , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Singapura , Fatores Socioeconômicos , Centros de Atenção TerciáriaRESUMO
INTRODUCTION: Vascular thrombosis is an important cause of pancreatic graft loss, and the vast majority is managed using graft pancreatectomy. There are limited reports and case series of successful salvage of the pancreas allograft. We describe a case of partial pancreatic allograft thrombosis presenting as ruptured pancreatic cyst successfully salvaged using a graft distal pancreatectomy. METHODS: We used descriptive retrospective analysis. RESULTS: A 29-year-old patient with type 1 diabetes and end-stage renal failure underwent a simultaneous pancreas kidney transplantation with immediate graft function. The cadaveric pancreas allograft was placed head up in the right iliac fossa with enteric exocrine drainage and standard vascular anastomosis. He presented with compressive symptoms on his bladder 5 months later, and a computed tomography (CT) showed a 4-cm cystic lesion in the body and tail of the pancreas allograft. Spontaneous rupture of the cyst occurred 3 weeks after the initial onset of symptoms with generalized abdominal pain. He underwent graft distal pancreatectomy with good recovery. He remains euglycemic, insulin-free with a normal renal function. Histology of the resected unhealthy graft showed an arterial thrombus with xanthogranulomatous inflammation and necrosis. CONCLUSION: Surgical salvage with graft distal pancreatectomy is feasible for partial pancreatic allograft thrombosis. Cystic lesion in the pancreas is a possible presentation of vascular thrombosis.
Assuntos
Aloenxertos/irrigação sanguínea , Transplante de Pâncreas/efeitos adversos , Pancreatectomia/métodos , Cisto Pancreático/diagnóstico , Artéria Esplênica , Trombose/diagnóstico , Adulto , Diabetes Mellitus Tipo 1/cirurgia , Humanos , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Masculino , Trombose/etiologia , Trombose/cirurgiaRESUMO
Donor safety is of paramount importance in addressing end-stage renal failure through living kidney transplantation. The United States Food and Drug Administration (FDA) issued a Class II recall on the use of Hem-o-lok (Teleflex, Limerick, Pennsylvania, United States) polymer clips on the renal artery in laparoscopic donor nephrectomy (LDN) in June 2006 following 3 reported cases of donor deaths secondary to slipped ligature. The National University Hospital of Singapore made the transition regarding hilar control in minimally invasive donor nephrectomy, from using polymer and titanium clips to transfixion techniques (pure or hand-assisted laparoscopic) via laparoscopic staples or intracorporeal suturing, respectively. This study assessed safety during the transition in arterial transfixion techniques in minimally invasive donor nephrectomy for both donors and recipients. Forty-five consecutive kidney donors underwent donor nephrectomy over a 2-year period starting from June 2010. A total of 37 donors who underwent LDN (pure laparoscopic or hand-assisted laparoscopic) were included in the analysis. Of the 37 patients, 23 kidney donors had renal arterial control using Hem-o-lok while 14 patients from November 2011 onward underwent transfixion of the renal artery. The 2 groups of donor who underwent renal arterial control by either clips ligature or transfixion technique were comparable. The outcomes for the recipients in each group were similar with no statistical difference between postoperative creatinine level, incidence of delayed graft function, or graft survival at 1 year. We conclude that the transition in renal arterial control technique to transfixion techniques in LDN in line with FDA recommendation is feasible and affords equivalent donor and recipient outcomes.
Assuntos
Transplante de Rim , Laparoscopia/instrumentação , Nefrectomia/métodos , Segurança do Paciente , Doadores de Tecidos , Humanos , Laparoscopia/métodos , PolímerosRESUMO
A positive T-cell cross-match is a well-established contraindication to deceased donor renal transplantation (DDRT); however, the significance of a positive B-cell cross-match (BCXM) remains debatable. Thus, given the high demand and scarce supply for deceased donor (DD) kidneys, only T- and B-cell cytotoxic cross-match-negative recipients were considered for DDRT in the past at our institution. Since September 2007, we have started performing DDRT across a historical positive cytotoxic BCXM. When a matched DD kidney became available, patients who were BCXM-positive (BCXM+) on historical sera would undergo repeat cross-match with current sera, using enhanced techniques. BCXM+ and current T-cell immunoglobulin (Ig)G cross-match-negative patients underwent transplantation with enhanced immunosuppression. Donor-specific anti-HLA antibodies (DSA) were tested for only in BCXM+ patients. The present study was designed to review outcomes of historical BCXM+ versus BCXM-negative (BCXM-) DDRT. Between September 2007 and October 2009, 11 BCXM+ and 50 BCXM- DDRT were performed. All patients were followed-up till October 31, 2010. Demographics and sensitization history of both groups were comparable. DSA were present in 6 (54.5%) BCXM+ patients, irrespective of their current cross-match status. All BCXM+ patients received induction immunosuppression with anti-thymocyte globulin, whereas only 60% of BCXM- patients had induction therapy. All BCXM+ patients and the majority of BCXM- patients received a calcineurin inhibitor-based maintenance regimen. DSA-positive patients received several sessions of plasmapheresis, followed by cytomegalovirus (CMV) hyperimmune globulin after every session. Graft and patient survivals were similar at 12 and 24 months in both groups. Their incidence of BK viremia, CMV antigenemia, and early acute rejection was also similar. The presence of DSA did not increase the risk for acute rejection. Performing DDRT across a positive BCXM with enhanced immunosuppression has enabled highly sensitized patients to receive a transplant with noninferior short-term outcomes compared with low-immunologic risk patients.
Assuntos
Linfócitos B/imunologia , Histocompatibilidade , Transplante de Rim/imunologia , Adulto , Linfócitos B/efeitos dos fármacos , Vírus BK/patogenicidade , Distribuição de Qui-Quadrado , Infecções por Citomegalovirus/virologia , Testes Imunológicos de Citotoxicidade , Função Retardada do Enxerto/etiologia , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Antígenos HLA/imunologia , Histocompatibilidade/efeitos dos fármacos , Teste de Histocompatibilidade , Humanos , Imunossupressores/uso terapêutico , Isoanticorpos/sangue , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Infecções por Polyomavirus/virologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Singapura , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Clinical practice guidelines recommend empiric antibiotic therapy for suspected tunnelled haemodialysis catheter-related infections (CRI), and the choice of antibiotics should be adjusted according to the local microbiological profile and antimicrobial sensitivities. We aim to describe the microbiology, antibiotic sensitivities, and clinical outcomes of CRI with tunnelled haemodialysis catheters in a multi-ethnic South-East Asian population. METHODS: Using a prospective vascular access registry, we identified 99 patients who had catheters removed for suspected or confirmed CRI (50.5% male, mean age 56.9 years) from January 1, 2007, till May 2009. We retrospectively retrieved microbiology, mortality and echocardiography data from the hospital electronic databases. RESULTS: There were 115 removal-unique cultures that yielded 75.7% Gram-positive and 24.3% Gram-negative isolates (15 removals were polymicrobial). Organisms isolated were methicillin-resistant Staphylococcus aureus (MRSA) 28.6%, methicillin-sensitive S. aureus 26.5%, coagulase-negative staphylococci 21.4%, Pseudomonas aeruginosa 10.2%, and others. Out of 8 patients who died, 7 had MRSA. Risk factors associated with mortality were Chinese race (p = 0.03), MRSA infection (p < 0.001), and older age (p < 0.001). CONCLUSION: Gram-positive isolates accounted for most tunnelled CRI and MRSA was highly associated with death. In sick patients presenting with suspected CRI, the preferred empiric antibiotic regimen should include agents active against both MRSA and P. aeruginosa.
Assuntos
Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/etnologia , Etnicidade/etnologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Vigilância da População , Infecções Estafilocócicas/etnologia , Adulto , Idoso , Sudeste Asiático/etnologia , Infecções Relacionadas a Cateter/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Infecções Estafilocócicas/diagnósticoRESUMO
Urinary tract cancers are the third most common cancers in renal transplant recipients (RTX). This study examined the impact of dialysis duration and native renal cyst(s) (NRC) on renal cell carcinoma (RCC) occurrence among 1036 RTX followed-up from 1995 to July 2007. Abdominal ultrasonography was planned within 1-month of transplant, then every 5 years, or 2 years if renal cysts developed. Based on presence and time of development of NRC, RTX were grouped into those with no (No-NRC), new (New-NRC), preexisting (Pre-NRC) and time-indeterminate NRC (TI-NRC). Ten asymptomatic RTX were diagnosed with RCC at a median of 5.8 years posttransplant and had 5-year graft and patient survivals of 90% and 100%, respectively, following appropriate therapy. RCC occurred only in Pre-NRC and TI-NRC who had significantly longer dialysis duration than No- or New-NRC (6.7 ± 3.9 and 3.3 ± 3.2 vs. 2.7 ± 3.1 and 2.6 ± 2.4 years, respectively). These results suggest that NRC and increased dialysis duration are risk factors for RCC posttransplant. Since early treatment of RCC gives excellent outcomes, regular ultrasonography performed within a month of transplantation, then every 5 years for those without cysts and every 2 years for those with cysts for early detection of RCC is recommended.
Assuntos
Carcinoma de Células Renais/etiologia , Doenças Renais Císticas/complicações , Neoplasias Renais/etiologia , Transplante de Rim/efeitos adversos , Rim/cirurgia , Diálise Renal/efeitos adversos , Adulto , Idoso , Carcinoma de Células Renais/epidemiologia , Carcinoma de Células Renais/patologia , Feminino , Humanos , Rim/diagnóstico por imagem , Doenças Renais Císticas/diagnóstico por imagem , Neoplasias Renais/epidemiologia , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento , UltrassonografiaRESUMO
PURPOSE: EBV-positive smooth muscle tumor (EBV+SMT) is a rare disease with no established therapy. We describe the largest single institution analysis in renal transplant recipients. It aims to define its clinical features and determine the expression of EBV latent genes as well as key molecular pathways. EXPERIMENTAL DESIGN: Patients with EBV+SMT were identified from the Singapore General Hospital Renal Transplant Registry database. These tumors were investigated for expression of EBV latent genes with Southern blots, EBV latent antigens, mammalian target of rapamycin (mTOR), Akt, p70 S6 kinase, and vascular endothelial growth factor using immunohistochemistry, as well as methylation status of cancer-related genes using methylation-specific PCR. RESULTS: Eight were found to be EBV+SMT in 1,123 transplant patients. All displayed indolent clinical courses and were unresponsive to immunosuppression reduction. Complete tumor regression was seen in one patient following administration of sirolimus. These tumors display the full range of known EBV latent genes. Immunohistochemistry with total and phosphorylated mTOR and Akt were positive for all patients, and vascular endothelial growth factor was positive in 25% of patients, suggesting activation of the mTOR/Akt pathway. Methylation of RASSF1A was found in all tissue samples, whereas promoter hypermethylation of RARbeta, GSTP1, DAPK, and p14 was observed in some samples. CONCLUSIONS: Our results suggest that these tumors display a EBV type III latency pattern. The mTOR pathway is also activated. EBV may play a role in silencing RASSF1A. EBV-specific immunotherapy, mTOR inhibitors, and demethylating agents are possible therapeutic options in this disease.
Assuntos
Antígenos Virais/metabolismo , Infecções por Vírus Epstein-Barr/metabolismo , Herpesvirus Humano 4/metabolismo , Proteínas Proto-Oncogênicas c-akt/metabolismo , Proteínas Quinases S6 Ribossômicas 70-kDa/metabolismo , Tumor de Músculo Liso/metabolismo , Adulto , Proteínas Reguladoras de Apoptose/metabolismo , Linhagem Celular Tumoral , Infecções por Vírus Epstein-Barr/patologia , Infecções por Vírus Epstein-Barr/virologia , Feminino , Glutationa S-Transferase pi/metabolismo , Herpesvirus Humano 4/imunologia , Humanos , Transplante de Rim , Masculino , Metilação , Pessoa de Meia-Idade , Regiões Promotoras Genéticas , Proteínas Quinases/metabolismo , Receptores do Ácido Retinoico/metabolismo , Tumor de Músculo Liso/patologia , Tumor de Músculo Liso/virologia , Serina-Treonina Quinases TOR , Proteínas Supressoras de Tumor/metabolismo , Fator A de Crescimento do Endotélio Vascular/metabolismoRESUMO
AIM: Several short-term studies have reported the efficacy of high-dose ARB in reducing proteinuria in patients with diabetic nephropathy. The benefits of long-term high-dose ARB losartan in IgA nephritis have not been explored. METHOD: This was a 6-year randomized trial in 207 patients with IgA nephritis comparing high-dose ARB (losartan 200 mg/day) with normal dose ARB (losartan 100 mg/day), normal dose ACEI (20 mg/day) and low-dose ACEI (10 mg/day). Multivariate ANOVA was used to test the effect of drug treatment on both eGFR and total urinary protein (TUP). RESULTS: Comparing patients on high-dose ARB (n = 63) with those on normal dose ARB (n = 43), normal dose ACEI (n = 61) and low-dose ACEI (n = 40), patients on high Dose ARB had significantly higher eGFR (p < 0.0005) and lower proteinuria (p < 0.005) at the end of the study. The loss in eGFR was 0.7 ml/min/year for high-dose ARB compared to 3.2 - 3.5 ml/ min/year for the other 3 groups (p = 0.0005). There were more patients on high-dose ARB with improvement in eGFR compared to other 3 groups (p < 0.001). CONCLUSION: Data from this study suggest that high-dose ARB therapy is more efficacious in reducing proteinuria and preserving renal function when compared with normal dose ARB and ACEI. In Year 5, patients on high-dose ARB had a gain in eGFR suggesting that there is possibility of recovery of renal function in these patients on long-term high-dose therapy.