Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series.

OBJECTIVE: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. METHODS: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. RESULTS: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). CONCLUSIONS: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

Veno-venous extracorporeal membrane oxygenation in patients with SARS-CoV-2 pneumonia in Brazil: a case series / Oxigenação por membrana extracorpórea venovenosa em pacientes com pneumonia por SARS-CoV-2 no Brasil: série de casos

ABSTRACT Objective: The world has been suffering from the COVID-19 pandemic. Some COVID-19 patients develop severe viral pneumonia, requiring mechanical ventilation and measures to treat refractory hypoxemia, such as a protective ventilation strategy, prone positioning, and the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO). We describe a case series of 30 COVID-19 patients who needed VV-ECMO at the Hospital Alemão Oswaldo Cruz, located in the city of São Paulo, Brazil. Methods: We included all patients who required VV-ECMO due to COVID-19 pneumonia between March of 2020 and June of 2021. Results: Prior to VV-ECMO, patients presented with the following median scores: SOFA score, 11; APPS score, 7; Respiratory ECMO Survival Prediction score, 2; and Murray score, 3.3. The 60-day-in-hospital mortality was 33.3% (n = 10). Conclusions: Although our patients had a highly severe profile, our results were similar to those of other cohort studies in the literature. This demonstrates that VV-ECMO can be a good tool even in a pandemic situation when it is managed in an experienced center.

RESUMO Objetivo: O mundo vem sofrendo com a pandemia de COVID-19. Alguns pacientes com COVID-19 desenvolvem pneumonia viral grave, necessitando ventilação mecânica e medidas para tratar a hipoxemia refratária, como estratégias de ventilação protetora, posição prona e uso de oxigenação por membrana extracorpórea venovenosa (ECMO-VV). Descrevemos uma série de casos de 30 pacientes com COVID-19 que necessitaram de ECMO-VV no Hospital Alemão Oswaldo Cruz, localizado na cidade de São Paulo, Brasil. Métodos: Foram incluídos todos os pacientes que necessitaram de ECMO-VV devido à pneumonia por COVID-19 entre março de 2020 e junho de 2021. Resultados: Antes da ECMO-VV, os pacientes apresentavam as seguintes medianas: escore SOFA de 11; escore APPS de 7; escore Respiratory ECMO Survival Prediction de 2; e escore de Murray de 3,3. A mortalidade hospitalar em 60 dias foi de 33,3% (n = 10). Conclusões: Apesar de nossos pacientes apresentarem um perfil de alta gravidade, nossos resultados foram semelhantes aos de outros estudos de coorte na literatura. Isso demonstra que a ECMO-VV pode ser uma boa ferramenta mesmo em uma situação de pandemia quando administrada em um centro experiente.

Increasing transplantability in Brazil: time to discuss Kidney Paired Donation / Doação renal pareada no Brasil: tempo para reflexão

Abstract Introduction: Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT. Discussion: KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America. Conclusion: KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.

Resumo Introdução: O transplante renal (TxR) é sabidamente o melhor tratamento para doença renal crônica. No Brasil, mais de 26 mil pacientes aguardam em lista atualmente. A doação renal pareada (DRP) oferece a um par de doador/receptor incompatível a possibilidade de trocar com outro par na mesma situação, representando uma estratégia para aumentar o número de TxR. Discussão: A DRP deixou de ser apenas uma ideia há mais de 20 anos. Atualmente é responsável por 16,2% dos TxR com doador vivo (TxRDV) nos EUA e 8% na Europa. Os resultados são semelhantes a outros TxRDV. Essa modalidade representa uma alternativa promissora, especialmente para os receptores hipersensibilizados que tendem a se acumular em lista de espera. A DRP não está limitada a países desenvolvidos. Em 2014, a Índia já publicava excelentes resultados. Na Guatemala, o primeiro TxRDV através de DRP aconteceu em 2011. Porém, a prática permanece limitada a casos isolados na América Latina. Conclusão: Programas de DRP com diferentes dimensões, regras para aceitação e critérios para alocação estão sendo desenvolvidos e expandidos mundialmente com o objetivo de atender às demandas dos pacientes. O aumento na capacidade de transplantar trazido pela DRP vem ao encontro especialmente das necessidades dos pacientes hipersensibilizados. O programa de TxR brasileiro tem maturidade para assumir o desafio de iniciar o programa de DRP, com o objetivo de beneficiar principalmente seus pacientes que estão em maior desvantagem por apresentarem baixas chances de transplante com doadores falecidos.

Increasing transplantability in Brazil: time to discuss Kidney Paired Donation.

INTRODUCTION: Kidney transplantation (KT) is the best treatment for chronic kidney disease. In Brazil, there are currently more than 26 thousand patients on the waitlist. Kidney Paired Donation (KPD) offers an incompatible donor-recipient pair the possibility to exchange with another pair in the same situation, it is a strategy to raise the number of KT. DISCUSSION: KPD ceased being merely an idea over 20 years ago. It currently accounts for 16.2% of living donors KT (LDKT) in the USA and 8% in Europe. The results are similar to other LDKT. It is a promising alternative especially for highly sensitized recipients, who tend to accumulate on the waitlist. KPD is not limited to developed countries, as excellent results were already published in India in 2014. In Guatemala, the first LDKT through KPD was performed in 2011. However, the practice remains limited to isolated cases in Latin America. CONCLUSION: KPD programs with different dimensions, acceptance rules and allocation criteria are being developed and expanded worldwide to meet the demands of patients. The rise in transplantability brought about by KPD mostly meets the needs of highly sensitized patients. The Brazilian transplant program is mature enough to accept the challenge of starting its KPD program, intended primarily to benefit patients who have a low probability of receiving a transplant from a deceased donor.

COVID-19 pneumonia in kidney transplant recipients-Where we are?

In late December 2019, China reported cases of respiratory illness in humans that involved a novel coronavirus SARS-CoV-2. On March 20, 2020, the first coronavirus disease 2019 (COVID-19) in Brazil was diagnosed, and by now, we present the report on the first case of COVID among transplant recipients in our country. A liver and kidney transplant patient with SARS-CoV-2 pneumonia without respiratory failure was treated in a clinical multimodal strategy consisting of symptomatic support therapy, immunosuppression reduction, use of anti-coronavirus drugs and heparin leading to a progressive improvement of patient symptoms till discharge. The authors also present a comprehensive review of published cases.

[Ten-year follow-up of kidney transplantation with living unrelated donor]. / Análise de 10 anos de seguimento de transplantesrenais com doador vivo não aparentado.

INTRODUCTION: In the current era of scarcity of kidneys available for transplantation, and chronic anti-HLA-mediated rejection as a main cause of graft loss, continuous demonstration of the long-term survival of grafts from living unrelated kidney donors (LURD) is paramount. OBJECTIVE: Analyze long-term kidney graft and patient outcomes using LURD, and compare them with living related donors (LRD). METHODS: We analyzed the 389 first renal transplantations performed with a living donor (281 LRD and 108 LURD), in a single center, from January 1998 through December 2007. RESULTS: There were no significant differences between LRD and LURD as refers to patient survival (89.1% vs. 84.7%, p = 0.40, respectively) and graft survival (81.1% vs. 68.9%, p = 0.77, respectively), 10 years post-transplantation. On Cox proportional regression model of multivariate analysis, panel reactive antibodies (PRA) > 10% and the occurrence of acute rejection in the first year posttransplantation were the only independent predictors of graft loss (HR 2.54, 95% CI 1.35 -4.78; p < 0.05 and HR 4.1, 95% CI 2.04 - 4.78; p < 0.05, respectively). CONCLUSION: LURD are an important source of organs for renal transplantation, with results similar to those obtained with LRD, regardless of HLA matching.

Análise de 10 anos de seguimento de transplantesrenais com doador vivo não aparentado / Ten-year follow-up of kidney transplantation with living unrelated donor

INTRODUÇÃO: No contexto atual da elevada escassez de órgãos para o transplante renal e do reconhecimento cada vez maior da rejeição crônica mediada por anticorpos anti-HLA como uma importante causa de perda do enxerto, uma contínua demonstração da boa evolução a longo prazo de transplantes renais com doadores vivos não aparentados (DVNA) é de suma importância. OBJETIVOS: Analisar a sobrevida do enxerto e dos pacientes transplantados com DVNA, e compará-la com doadores vivos aparentados (DVA). MÉTODOS: Foram analisados 389 primeiros transplantes renais com doador vivo realizados em um único centro, entre janeiro de 1998 e dezembro de 2007, 281 com DVA e 108 com DVNA. RESULTADOS: Não houve diferença significativa na sobrevida dos pacientes (89,1 por cento vs. 84,7 por cento, p = 0,40) e do enxerto (81,1 por cento vs. 68,9 por cento, p = 0,77), em 10 anos de seguimento, entre DVA e DVNA, respectivamente. Na análise multivariada do modelo de regressão proporcional de Cox, a reatividade contra painel (PRA) > 10 por cento e a ocorrência de rejeição aguda no 1º ano após o transplante foram os únicos preditores independentes de perda do enxerto (OR 2,54, IC 95 por cento 1,35 - 4,78; p < 0,05 e OR 4,1, IC 95 por cento 2,04 -4,78; p < 0,05, respectivamente). CONCLUSÃO: Transplantes renais com DVNA representam uma importante fonte de órgãos para suprir uma crescente demanda, com resultados semelhantes aos transplantes com DVA, independente da compatibilidade HLA.

INTRODUCTION: In the current era of scarcity of kidneys available for transplantation, and chronic anti-HLA-mediated rejection as a main cause of graft loss, continuous demonstration of the long-term survival of grafts from living unrelated kidney donors (LURD) is paramount. OBJECTIVE: Analyze long-term kidney graft and patient outcomes using LURD, and compare them with living related donors (LRD). METHODS: We analyzed the 389 first renal transplantations performed with a living donor (281 LRD and 108 LURD), in a single center, from January 1998 through December 2007. RESULTS: There were no significant differences between LRD and LURD as refers to patient survival (89.1 percent vs. 84.7 percent, p = 0.40, respectively) and graft survival (81.1 percent vs. 68.9 percent, p = 0.77, respectively), 10 years post-transplantation. On Cox proportional regression model of multivariate analysis, panel reactive antibodies (PRA) > 10 percent and the occurrence of acute rejection in the first year posttransplantation were the only independent predictors of graft loss (HR 2.54, 95 percent CI 1.35 -4.78; p < 0.05 and HR 4.1, 95 percent CI 2.04 - 4.78; p < 0.05, respectively). CONCLUSION: LURD are an important source of organs for renal transplantation, with results similar to those obtained with LRD, regardless of HLA matching.

Hyperhomocyst(e)inemia in chronic stable renal transplant patients

PURPOSE: Hyperhomocyst(e)inaemia is an important risk factor for atherosclerosis, which is currently a major cause of death in renal transplant patients. The aim of this study was to assess the influence of immunosuppressive therapy on homocyst(e)inemia in renal transplant recipients. METHODS: Total serum homocysteine (by high performance liquid chromatography), creatinine, lipid profile, folic acid (by radioimmunoassay-RIA) and vitamin B12 (by RIA) concentrations were measured in 3 groups. Group I patients (n=20) were under treatment with cyclosporine, azathioprine, and prednisone; group II (n=9) were under treatment with azathioprine and prednisone; and group III (n=7) were composed of renal graft donors for groups I and II. Creatinine, estimated creatinine clearance, cyclosporine trough level, lipid profile, folic acid, and vitamin B12 concentrations and clinical characteristics of patients were assessed with the aim of ascertaining determinants of hyperhomocyst(e)inemia. RESULTS: Patient ages were 48.8 ñ 15.1 yr (group I), 43.3 ñ 11.3 yr (group II); and 46.5 ñ 14.8 yr (group III). Mean serum homocyst(e)ine (tHcy) concentrations were 18.07 ñ 8.29 mmol/l in renal transplant recipients; 16.55 ñ 5.6 mmol/l and 21.44 ñ 12.1 mmol/l respectively for group I (with cyclosporine) and group II (without cyclosporine) (NS). In renal donors, tHcy was significantly lower (9.07 ñ 3.06 mmol/l; group I + group II vs. group III, p<0.008). There was an unadjusted correlation (p<0.10) between age (r=0.427; p<0.005) body weight (r=0.412; p<0.05), serum creatinine (r=0.427; p<0.05), estimated creatinine clearance (r=0.316; p<0.10), and tHcy in renal recipients (group I +II). Independent regressors (r2=0.46) identified in the multiple regression model were age (coefficient= 0.253; p=0.009) and serum creatinine (coefficient=8.07; p=0.045). We found no cases of hyperhomocyst(e)inemia in the control group. In contrast, 38 per cent of renal recipients had hyperhomocyst(e)inemia: 7 cases (35 per cent) on cyclosporine and 4 (45 per cent) without cyclosporine, based on serum normal levels. CONCLUSIONS: Renal transplant recipients frequently have hyperhomocyst(e)inemia. Hyperhomocyst(e)inemia in renal transplant patients is independent of the scheme of immunosuppression they are taking. The older the patients are and the higher are their serum creatinine levels, the more susceptible they are to hyperhomocyst(e)inemia following renal transplantation