Evaluation of microaeration strategies in the digestion zone of UASB reactors as an alternative for biogas desulfurization.

This study aimed at evaluating the microaeration as an alternative for hydrogen sulfide removal from biogas of UASB reactors treating sewage. The set-up consisted of two pilot-scale UASB reactors, including a conventional anaerobic and a modified UASB reactor, operated under microaerated conditions. Air was supplied in the digestion zone, at 1 and 3 m from the bottom of the reactor, and three different air flows were investigated: 10, 20, and 30 mL.min-1, corresponding to 0.003, 0.005 and 0.005 LO2/Linfluent, respectively. The main results showed that the microaeration provided a substantial decrease in hydrogen sulfide concentrations when compared to the concentrations observed in the biogas of the anaerobic UASB reactor. Hydrogen sulfide concentrations remained below 70 ppmv throughout the experimental period, corresponding to an average removal efficiency of 98%. Although a decrease in methane concentrations in biogas was observed, the feasibility of energy use would not be affected. The effect of microaeration on the overall performance of the reactor was evaluated, however, no significant differences were observed. The feasibility of limiting aeration conditions in the reactor digestion zone as an efficient alternative for hydrogen sulfide removal from biogas was demonstrated.

Lymphocyte subsets and Langerhans cells in the skin of kidney transplant recipients under three different immunosuppressive regimens.

BACKGROUND: Renal transplant recipients (RTRs) are at increased risk of developing skin cancer; however, the role of immunosuppression is not yet fully understood. In this study, we evaluated the immunohistochemical changes in the skin of RTRs under three different immunosuppression regimens: mTOR inhibitors (mTORi), sirolimus or everolimus, mycophenolic acid (MPA) precursors such as mycophenolate sodium or mofetil, or azathioprine (AZA). METHODS: We evaluated biopsies of sun-exposed and sun-protected skin for immunohistochemical quantification of B lymphocytes (CD20+ ), T lymphocytes (CD3+ , CD4+ , and CD8+ ), and Langerhans cells (LCs) (CD1a+ ) in 30 RTRs and 10 healthy controls. The RTRs were divided into three groups: mTORi (n = 10), MPA (n = 10), and AZA (n = 10). RESULTS: No differences were observed in the number of B lymphocytes. However, a significant decrease in the number of T lymphocytes and LCs was observed in both sun-protected and sun-exposed skin in the AZA and MPA groups, although to a lesser degree in the latter group. The skin of the mTORi group did not differ from that of the control group in terms of the number of B and T lymphocytes and LCs. CONCLUSIONS: Patients treated with mTORi exhibit preserved cellular elements related to cutaneous immune surveillance. The use of AZA induced a greater degree of skin immunosuppression than in the control group, as demonstrated by the decrease in T lymphocytes and LCs.

Performance and bacterial diversity of bioreactors used for simultaneous removal of sulfide, solids and organic matter from UASB reactor effluents.

Two bioreactors were investigated as an alternative to post-treatment of effluent from an upflow anaerobic sludge blanket (UASB) reactor treating domestic sewage, with an aim of oxidizing sulfide into elemental sulfur, and removal of solid and organic material. The bioreactors were operated at different hydraulic retention times (HRTs) (6, 4, and 2 h) and in the presence or absence (control) of packing material (polypropylene rings). Greater sulfide removal efficiencies - 75% (control reactor) and 92% (packed reactor) - were achieved in both reactors for an HRT of 6 h. Higher organic matter (COD) and solid (TSS) removal levels were observed in the packed reactor, which produced effluent with low COD (100 mg CODL-1) and TSS concentrations (30 mg TSSL-1). Denaturing gradient gel electrophoresis results revealed that a metabolically diverse bacterial community was present in both bioreactors, with sequences related to heterotrophic bacteria, sulfur bacteria (Thiocapsa, Sulfurimonas sp., Chlorobaculum sp., Chromatiales and Sulfuricellales), phototrophic purple non-sulfur bacteria (Rhodopseudomonas, Rhodocyclus sp.) and cyanobacteria. The packed reactor presented higher extracellular sulfur formation and potential for elemental sulfur recovery was seen. Higher efficiencies related to the packed reactor were attributed to the presence of packing material and higher cell retention time. The studied bioreactors seemed to be a simple and low-cost alternative for the post-treatment of anaerobic effluent.

Drought promotes increases in total mercury and methylmercury concentrations in fish from the lower Paraíba do Sul river, southeastern Brazil.

Bioaccumulation of mercury and methylmercury in fish represents a serious risk to human beings. Extreme climate events like droughts may increase the trophic transfer of contaminants and net methylation of mercury. The present study assessed the influence of the 2014 drought on total mercury and methylmercury levels in fish from the lower Paraiba do Sul river basin. Contaminant levels were compared for Pimelodus fur, Pachyurus adspersus, Pimelodella lateristriga, Oligosarcus hepsetus, and Crenicichla lacustris captured in five sites in 2013 (N = 212) and 2014 (N = 231). The results indicate that levels of contaminants were higher during the drought in most species. Rainfall was weakly and negatively correlated with total mercury levels in most of the species. The weak relationship between these two variables was due to the indirect influence of rainfall on mercury bioaccumulation. In summary, drought increased the levels of two contaminants in fish.

Diagnóstico ecocardiográfico e tratamento de cardiomiopatia dilatada em tamanduá- bandeira ( Myrmecophaga trydactila ) mantido em cativeiro: relato de caso / Echocardiographic diagnosis and treatment of dilated cardiomyopathy in captive giant anteater (Myrmecophaga trydactila): case report

A cardiomiopatia dilatada é uma doença de caráter crônico, que compromete a função cardíaca, resultando em desequilíbrio da circulação sanguínea e da homeostase corporal do animal. Este relato apresenta a evolução do quadro clínico e o tratamento de cardiomiopatia dilatada em um exemplar cativo de tamanduá-bandeira. O animal apresentou quadro clínico de insuficiência cardíaca e foi submetido a duas baterias de exames laboratoriais e de imagem em um período de três meses. Posteriormente, foi iniciado o tratamento com pimobendan e suplementação de taurina, resultando em resposta positiva e melhora dos sinais clínicos do paciente. Os achados ecocardiográficos do caso foram compatíveis com cardiomiopatia dilatada com sinais evidentes de diminuição progressiva das frações de ejeção, bem como encurtamento e aumento expressivo das câmaras cardíacas, quando se comparou este caso ao de cães de grande porte e animais saudáveis da mesma espécie. O tratamento com inotrópico positivo, suplementação dietética de taurina e diuréticos se mostrou eficiente em controlar os sinais clínicos do animal.(AU)

The dilated cardiomyopathy it is a chronic disease that leads to a cardiac dysfunction, resulting in unstable blood circulation and specimen body homeostasis. This description shows the dilated cardiomyopathy evolution and treatment in a giant anteater captive model. The patient presented cardiac insufficient clinical condition and was submitted to two sets of laboratorial and image exams in three months. Furthermore, the treatment started with pimobendam and taurine supplementation, leading to satisfactory response to treatment and clinical improvement. The echocardiographic findings were compatible with dilated cardiomyopathy, moreover clear evidence of progressive reduction at the ejection portions and shortening and expressive increase of the cardiac chamber when compared to large dogs and healthy animals of the same species. Treatment with positive inotropic and taurine dietary supplement revealed as effective in clinical managementr.(AU)

Organotropism of methylmercury in fish of the southeastern of Brazil.

This is one of the first studies to evaluate the effect of biometric variables (total length and weight), diet, and abiotic matrices (sediment and water column) on the bioaccumulation of methylmercury in tissues (muscle, liver, and gills) of four fish (two carnivore-invertivores, Pimelodus fur and Pachyurus adspersus; one carnivore-piscivore, Oligosarcus hepsetus; and one omnivore, Pimelodella lateristriga) in the lower section of a river in southeastern Brazil. Samples of fish (n = 120), water (n = 5) and sediment (n = 5) were collected at five sites characterized by pollution with mercury due to the use of organomercury fungicides and stream bed gold mining, commonly carried out in that section of the river in the 1980s. The results show that biometric variables are strongly correlated with methylmercury levels in muscle (r = 0.61, p < 0.0005) of P. fur. As a rule, concentrations of total mercury and methylmercury did not vary considerably between the organs of the species of different food habits, because of the environmental conditions in the study area. Despite the low concentrations of mercury in sediments (<0.05 mg kg-1 wet. wt), this compartment is a representative source of this pollutant for the organisms investigated, due to the close contact these animals keep with it in view of the low water columns in that section of the river.

Clinical Characteristics and Outcomes of Influenza A Infection in Kidney Transplant Recipients: A Single-Center Experience.

BACKGROUND: Influenza virus infection can cause severe illness in certain high-risk groups. Solid organ and hematopoietic stem cell transplant recipients have been shown to present a greater risk for severe influenza and complications than the general population. METHODS: Retrospective descriptive cohort study of the features and outcomes of influenza infection in renal transplant recipients from July 2009 to May 2014. RESULTS: Thirty-one patients were diagnosed with influenza A infection within the specified period. The incidence of influenza A was 26.5 cases/1,000 person-years. Hospital admission (68%), secondary bacterial pneumonia (68%), intensive care unit admission (14%), and mortality rate (14%) were higher than reported for immunocompetent patients. CONCLUSIONS: Influenza diagnosis and treatment should be prompt in immunocompromised patients to reduce the risk of complications. Patients who require intensive care owing to respiratory and hemodynamic complications present high mortality rates.

Seroconversion of 2009 pandemic influenza A (H1N1) vaccination in kidney transplant patients and the influence of different risk factors.

BACKGROUND: Influenza may present a high morbidity and mortality in solid organ transplanted patients (SOTP). Annual influenza virus vaccine is recommended for SOTP. However, low levels of seroconversion in SOTP have been reported. The aim of this study was to evaluate the immunogenicity of 2009 pandemic influenza A (H1N1) - A(H1N1)pdm09--vaccine in kidney transplant patients and to analyze which features might affect seroconversion. METHODS: This study was conducted from March to August 2010 at the Renal Transplantation Unit of University of São Paulo, Brazil. A total of 85 renal transplant patients attending the outpatient unit received one 15-µg intramuscular dose of A(H1N1) pdm09 influenza vaccine (reassortant vaccine virus A/California/7/2009 [NYMC X-179A]). Blood samples were collected immediately before and 21 days after the vaccine was given. Antibody response was measured by the standard hemagglutination-inhibition (HI) assay. The primary immunogenicity endpoint for this study was seroconversion in previously seronegative patients (HI titers <1:40), and the secondary endpoint was the identification of features that could affect seroconversion in this population. RESULTS: Five (5.9%) patients presented HI titers prevaccination ≥ 1:40 and were excluded from further analysis. Seroconversion in previously negative patients occurred in 27 (34%) of 80 patients. Prevaccination HI titers geometrical mean was 5.8 and postvaccination 19.6 (ratio 3.4). Significant seroconversion rate factors were female gender, non-Caucasian ethnicity, and post-transplant time before vaccination. No impact was seen on seroconversion for age, donor type, tacrolimus and cyclosporine blood levels, renal function, or blood lymphocyte counts. Mycophenolate (MPA) showed a lower rate of seroconversion when compared with azathioprine. Tacrolimus and cyclosporine had similar seroconversion rates. Sirolimus use was associated with the highest rate of seroconversion, although these patient numbers were low. Immunosuppresssion containing MPA was considerably less effective in seroconversion than drug combinations with no MPA. Patients receiving sirolimus had more chance of seroconversion. HI titers geometric means pre/post vaccine were as follows: MPA (n = 56): 5.8/12.8; tacrolimus (n = 50): 5.9/16.2; cyclosporine (n = 18): 5.4/24.2; azathioprine (n = 19): 6.2/51.6; and sirolimus (n = 6): 8/80. By univariate analysis, being female and non-White were variables associated with 3.3 times more chance of seroconversion than being male and White. In the multivariate analysis, the variables remaining in the model showed similar hazard ratios. CONCLUSIONS: In this study, the monovalent A(H1N1)pdm09 influenza vaccine demonstrated low rates of seroconversion, particularly in patients on MPA, but with potentially higher response rates in patients on sirolimus.

Yellow fever vaccination in organ transplanted patients: is it safe? A multicenter study.

BACKGROUND: Yellow fever (YF) may be very serious, with mortality reaching 50%. Live attenuated virus YF vaccine (YFV) is effective, but may present, although rare, life-threatening side effects and is contraindicated in immunocompromised patients. However, some transplant patients may inadvertently receive the vaccine. METHODS: A questionnaire was sent to all associated doctors to the Brazilian Organ Transplantation Association through its website, calling for reports of organ transplanted patients who have been vaccinated against YF. RESULTS: Twelve doctors reported 19 cases. None had important side effects. Only one had slight reaction at the site of YFV injection. Eleven patients were male. Organs received were 14 kidneys, 3 hearts, and 2 livers. Twelve patients received organs from deceased donors. Mean age at YFV was 45.6 ± 13.6 years old (range 11-69); creatinine: 1.46 ± 0.62 mg/dL (range 0.8-3.4); post-transplant time: 65 ± 83.9 months (range 3-340); and time from YFV at the time of survey: 45 ± 51 months (range 3-241). Immunosuppression varied widely with different drug combinations: azathioprine (7 patients), cyclosporine (8), deflazacort (1), mycophenolate (10), prednisone (11), sirolimus (3), and tacrolimus (4). CONCLUSIONS: YFV showed no important side effects in this cohort of solid organ transplanted patients. However, owing to the small number of studied patients, it is not possible to extend these findings to the rest of the transplanted population, assuring safety. Therefore, these data are not strong enough to safely recommend YFV in organ transplanted recipients, as severe, even life-threatening side effects may occur.

Avaliação da adequação legal de receitas e notificações de receita de medicamentos sujeitos a controle especial dos setores públicos e privados / Evaluation of the legal prescription and notifications adequacy for special control medicinesin the public and private sectors

Os objetivos desta pesquisa foram avaliar a adequação legal de receitas de controle especial e notificações de receitas dispensadas em uma Drogaria de Varginha ? MG, estabelecer uma comparação entre as prescrições provenientes da rede pública e privada e detectar as classes de medicamentos mais prescritas. Analisaram-se 960 prescrições através de um formulário com itens obrigatórios de acordo com a legislação vigente. Os dados obtidos foram analisados pelo Teste Qui-quadrado, utilizando a origem das notificações e receitas como desfecho. Considerando as receitas; a única variável que apresentou diferença entre os setores público e privado foi a descrição por extenso da quantidade de medicamento, que foi mais adequadamente cumprida pelo setor privado. Em relação às notificações, a legibilidade foi significativamente mais freqüente em notificações provenientes de centros públicos, enquanto a designação da Unidade Federativa e a descrição por extenso da quantidade de medicamento foram mais presentes no setor privado. Por outro lado, a descrição completa da posologia, da data da notificação, a presença de carimbo e descrição da forma farmacêutica foram mais adequadas no setor público. Nenhuma das prescrições foi considerada totalmente adequada aos dados exigidos pela Portaria 344/98. As classes medicamentosas mais prescritas foram os benzodiazepínicos em notificações de receita e os antidepressivos em receituário de controle especial. Concluiu-se que a prescrição de medicamentos sujeitos a controle especial apresenta falhas de acordo com a legislação vigente.

The objectives of the present study were to evaluate the legal prescription adequacy in one drugstore located in the south of Minas Gerais state, in order to establish comparisons between the prescriptions of public and private services and to detect the most commonly classes of medicines prescribed. It was analyzed 960 prescriptions in accordance with the current law. The data were analyzed by descriptive statistics and compared using frequency distribution test(Chi-square test) considering private and public sources of prescription as the dependent variable. Considering special control prescriptions, the extensive description of the amount of medicine was fulfilled more frequently by the private sector. However, for the notifications; legibility, dosage, pharmaceutical form, date of issue and presence of stamp were more frequently present in the public service, while assignment of the Federative Union, the extensive description of the amount of medicine and the dosage was more present in the private sector. None of the evaluated prescriptions was considered totally adjusted with law 344/98. The prescribed medicines more commonly found were benzodiazepines for prescription notifications and antidepressants in special control prescriptions. It was concluded that the medicine prescriptions subjected to special control are frequently not adequate to the current law.

Incidence of delayed graft function in cadaveric kidney transplants in Brazil: a multicenter analysis.

To evaluate the frequency of delayed graft function (DGF) in kidney transplant centers in Brazil, we sent a questionnaire requesting information on the number of cadaveric donor kidney transplants performed during the years 2000, 2001, and 2002, the number of early nonfunctioning grafts, and the number of patients on dialysis during the first posttransplant week with subsequent recovery. Among all centers performing more than 50 kidney transplants during the last year of evaluation, 6, performing 612 cadaveric kidney transplants during the study period, replied to the questionnaire. Sixty procedures (9.7%) resulted in nonfunctioning grafts, while 312 (55.6%) patients required dialysis during the first Ptx week: 216 (53.9%) in 2000, 189 (62.3%) in 2001, and 216 (51.6%) in 2002. The frequency of DGF during the study period was higher than that noted by several previous foreign studies. To better evaluate the possible causes of this finding, a more extensive and focused study is warranted.

Renal transplantation in systemic lupus erythematosus. A case control study of 45 patients.

BACKGROUND: Outcome and the issue of recurrence of disease in systemic lupus erythematosus (SLE) renal transplant recipients is still a matter of controversy. There is a lack of comparative studies with non-SLE patients. The aim of this paper is to compare renal transplantation in lupus patients with a similar matched non-SLE group. METHODS: Forty-five patients with systemic lupus erythematosus subjected to 48 kidney transplants were studied. For comparative purposes, a case-control population was selected, matched for gender, race, type of donor, age, and time of transplantation. Patients with non-glomerulonephritis diseases were excluded. RESULTS: No differences in acute episodes of rejection, causes of kidney loss or patient death were observed. General as well as infectious complications were similar. Pregnancy rates and outcomes were similar with no deleterious effect on patients or grafts. Actuarial 1- and 5-year patient survivals (97.7 and 91.1% for SLE and 95.4 and 87% for controls, respectively) and graft survivals (93.1 and 80.7% for SLE and 88.8 and 70.2% for controls, respectively) were similar. Long-term renal function expressed by serum creatinine was the same. No differences in immunosuppressive drug (azathioprine, prednisone, and cyclosporin) requirements were found. Clinical SLE recurrence was suspected only once (a patient with thrombocytopenia, hypocomplementaemia with low complement levels and positive antiplatelet antibodies). Two SLE patients showed mesangial proliferative glomerulonephritis compatible with recurrence. Both grafts were lost. Two further patients showed membranous glomerulonephritis with an immunofluorescence pattern compatible with recurrence. A fifth patient had necrotizing arteritis which recovered after treatment with cyclophosphamide and another patient showed focal and segmental glomerulosclerosis. Histology of biopsies from five patients in the control group showed signs compatible with recurrence of focal and segmental glomerulosclerosis and membranous glomerulonephritis. There was a wide variation in serum levels of antinuclear antibodies. A wide variation in complement levels was also observed, but with a tendency towards low C4 levels. CONCLUSIONS: The safety of renal transplantation in SLE patients is equivalent to a matched case-control group with a similar rate of recurrence of disease.

The role of experimental chronic renal failure and aluminium intoxication in cellular immune response.

BACKGROUND: A positive correlation between successful kidney transplantation, few rejection episodes, greater susceptibility to infection and morbidity in patients with high tissue levels of aluminium (Al) indicate that the metal may play a role in the immune response. The aim of this study was to determine if experimental aluminium intoxication could result in significant changes in lymphocyte activity in uraemic and nonuraemic rats. METHODS: Lewis rats were divided into four groups: normals (N), nephrectomized control (U), and Al-treated (N + Al) and nephrectomized Al-treated (U + Al), which received a cumulative dose of 30 mg Al over a 4-week period. Al quantification, histology, histochemical analysis and immunological assays were performed after Al intoxication. RESULTS: High tissue levels of Al and positive histochemical staining in bones were seen in Al-treated rats. Bone histology revealed osteomalacia in U + Al rats. No statistical differences were observed in mixed lymphocyte cultures from controls and Al-treated rats, whereas U and Al-treated rats showed a decrease in lymphoproliferative response to mitogen and natural killer cell cytotoxic activity. A decreased helper T lymphocyte: cytotoxic T lymphocyte cell ratio and a reduction in interleukin-2 production were observed only in the U + Al group. A reduced number of total T lymphocytes was detected in the spleens of all Al-treated rats. CONCLUSIONS: These findings suggest that aluminium toxicity may contribute to immunological impairment in chronic renal failure.

Comparaçäo entre a dosagem de ciclosporina-A em amostras de sangue coletadas em papel de filtro e pela técnica habitual / Comparison between the dosage of cyclosporin-A in blood samples collected on filter paper and by the ordinary technique

A monitorizaçäo dos níveis sanguíneos da ciclosporina A (CsA) é fundamental para o uso racional deste medicamento. No Brasil, poucos laboratórios realizam dosagem de CsA, embora haja muitos centros de transplante. Desta forma, surgiu o problema de fazer chegar a amostra de sangue ao laboratório. A coleta de sangue em papel de filtro é técnica já empregada, em situaçöes especiais, há muito tempo. OBJETIVOS. Correlacionar a fidedignidade da dosagem de CsAem amostras de sangue coletadas em papel de filtro com as técnicas habituais de coleta. MÉTODOS. Foram estudados 20 pacientes transplantados com rim de cadáver em uso de CsA, associada à azatioprina e à prednisona. Noventa e cinco amostras de sangue foram coletadas em EDTA e subdivididas em duas alíquotas. Uma delas foi encaminhada, da forma habitual, para o laboratório clínico para dosagem sanguínea de CsA. Da outra alíquota foram pipetados 20 microlitros sobre papel de filtro que, após secagem, foram enviados, pelo correio, para outro laboratório, onde, após eluiçäo, foi feita a dosagem de CsA. Nos dois casos a técnica de dosagem foi a mesma, usando-se o radioimunoen-saio com anticorpo policlonal anti-CsA. RESULTADOS. A correlaçäo linear entre ambas as dosagens resultou r = 0,81, näo havendo diferença significativa. CONCLUSÖES. Este método se presta, portanto, para ser usado na prática clínica, o que, em país de dimensöes continentais como o Brasil, pode ser muito útil

[Comparison of the determination of cyclosporin-A in blood samples collected on filter paper and by the ordinary technique]. / Comparação entre a dosagem de ciclosporina-A em amostras de sangue coletadas em papel de filtro e pela técnica habitual.

Monitoring cyclosporin-A (CsA) blood levels is of utmost importance for the rational use of this drug. Although many centers perform transplants, in Brazil there are few laboratories able to measure CsA blood levels. Therefore making blood samples reach the laboratory emerged as a problem. Collection of blood on filter paper has been a technique used for a long time in special cases. PURPOSE--To confirm the usefulness of measuring CsA blood levels in blood samples collected on filter paper and in the usual way. METHOD--We studied twenty renal cadaver kidney recipients who were receiving CsA, azathioprine and prednisone. Ninety five blood samples were collected and divided into two aliquots. One of them was sent routinely to one laboratory to perform whole blood CsA measurements. From the other aliquot, 20 microliters were pipetted on filter paper. When dried they were mailed to the other laboratory, where, after elution, CsA was measured. In both cases radioimmunoassay with polyclonal antibody was used. RESULTS--Linear correlation between both measurements revealed r = 0.81 with no statistical difference. CONCLUSION--The technique showed to be useful in clinical practice. In countries with continental size, as Brazil, it may be very helpful.

The role of experimental aluminum intoxication in allogeneic immunoresponse.

To evaluate the immunological properties of aluminum (Al) in experimental Al intoxication in rats, we performed heart transplantation and in vitro experiments. Lewis (Lew) rats were intoxicated with intraperitoneal injections of AlCl3. heart transplants were performed using Brown-Norway (BN) rats as donors. Isotransplants and normal Lew were used as controls. No differences in survival were observed. Unidirectional mixed lymphocyte cultures (MLC) and Concanavalin A (Con A)-stimulated cultures were prepared using spleen cells from normal and Al-intoxicated Lew rats. No differences were found in unidirectional MLC. Intoxicated cells showed a less intense response to con A than did normal cells. In conclusion, we could not detect an immunosuppressive role of Al intoxication in experimental cardiac transplantation or in MLC. However, the depressed Con A blastogenic response of Al-intoxicated cells may reflect an immunological role yet to be defined.

[Cyclosporin A: experience of the Renal Transplant Unit of the Clinical Hospital of the Medical College of the University of Sao Paulo]. / Ciclosporina A: experiência da Unidade de Transplante Renal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.

The authors report their experience using cyclosporine-A (CsA) in renal transplant patients. When compared with azathioprine/prednisone, CsA contributed significantly to a better graft and patient survival, either if used associated with prednisone of with azathioprine plus prednisone. CsA was also used in substitution to azathioprine in patients with hepatopathy attributed to azathioprine toxicity. The initial results are promising. The association of CsA and azathioprine with corticosteroids withdrawal was used as an attempt to allow normal growth in children. This seems to be the best choice of treatment for children. Careful monitoring of CsA blood levels avoids, or at least, minimizes nephrotoxicity. To achieve therapeutic CsA levels, patients with liver damage need lower, while children need higher oral CsA doses. To summarise: when CsA in carefully used, it is an excellent immunosuppressive drug.