Retrospective analysis of percutaneous intervention of the renal artery in transplanted kidneys in children and adolescents at a tertiary public hospital.

BACKGROUND: This study evaluated the long-term effects of percutaneous intervention in children and adolescents with transplant renal artery stenosis (TRAS). METHODS: Twenty patients had significant stenosis (>50%) and underwent percutaneous transluminal angioplasty (PTA/stenting) (TRAS group-intervention); 14 TNS (non-significant group -control) patients did not have significant stenosis (≤50%) and were treated clinically. The combined primary endpoints were death from all causes and late graft failure. The secondary endpoints were serum creatinine (SCr), systolic blood pressure (SBP), and diastolic blood pressure (DBP). RESULTS: No statistically significant difference was found between TRAS-Intervention(N = 20) and TNS groups-Control (N = 14) for these clinical parameters: deaths, 1 (5.0%) vs. 0 (0.0%) (p = 1.000) and graft loss, 4 (20.0%) vs. 2 (14.3%) (p = 1.000). For the secondary endpoints, after 1 month and 1 year the values of SCr, SBP, and DBP were similar between the two groups but not statistically significant. DISCUSSION: In the TRAS group (intervention), the stent implantation was beneficial for treating refractory hypertension and reducing blood pressure (BP) in children and adolescents. Despite the outcomes being similar in the two groups, it can be inferred that the patients in the TRAS group (intervention) would have had a worse outcome without the percutaneous intervention. CONCLUSION: TRAS treatment with stenting can be considered for children and adolescents. Because the sample in the present study comprised of only a specific population, further studies are needed for generalization. TRIAL REGISTRATION: The trial was registered at clinictrials.gov with trial registration number NCT04225338.

Serum uric acid concentration is associated with lower glomerular filtration rate in children undergoing kidney transplantation.

BACKGROUND: The relationship between serum concentration of uric acid (UA) and chronic kidney disease is complex due to many confounding variables. There is currently debate over whether hyperuricemia acts as a marker of kidney disease or as an independent risk factor. OBJECTIVES: To test the impact of serum UA concentration on the estimated glomerular filtration rate (GFR) of children undergoing kidney transplantation. PATIENTS AND METHODS: Prospective longitudinal study of children and adolescents after kidney transplantation. We analyzed clinical, anthropometric, and laboratory data at pre-transplant and 1, 3, and 6 months after transplant. We developed models of repeated measures analysis, using the generalized estimating equations technique for the outcome evolution of the estimated GFR at 1, 3 and 6 months. High serum UA concentration at 1 and 3 months was modeled as the main exposure variable. RESULTS: We included 103 transplant patients. In a model adjusted for time, recipient sex and age, the occurrence of acute rejection episodes, and the estimated glomerular filtration at baseline, the trajectory of GFR exhibited an inverse relationship with UA (ß = -7.1, 95% CI: -11.5 to -2.6, p < .01). CONCLUSION: Serum UA increase was associated with lower graft function over time.

Long-term clinical outcomes of patients with nonsignificant transplanted renal artery stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis. METHOD: This retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014. RESULTS: During this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss. CONCLUSION: Age, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.

Detection of polyomavirus microRNA-5p expression in saliva shortly after kidney transplantation.

Background: MicroRNAs (miRNAs) of polyomavirus (PyV) are present in several biological fluids and are suggested to be relevant viral factors for monitoring its persistence. Aim: To evaluate the effect of an immunosuppressive regimen on the status of PyV-miRNA-5p in the oral cavity. Materials and Methods: The JCPyV, BKPyV, MCPyV miRNA-5p were investigated in paired saliva and plasma samples obtained from 23 patients before and shortly after renal-transplantation by using real-time RT-PCR. Results: Overall, within a short-time after transplantation, patients exhibited decreased numbers of leukocyte and lymphocyte as well as low levels of creatinine. During the clinical management of the patients, a significant amount of saliva samples were positive for JCPyV and BKPyV miRNA-5p (range: 26%-91%) compared to paired plasma samples (range: 9%-35%). Among the two polyomaviruses showing positive expression of miRNA-5p, BKPyV presented the highest positivity in saliva (91%) and MCPyV-miRNA-5p was constantly negative in both saliva and plasma samples. Compared to the time before transplantation, a significant reduction in the expression of JCPyV-miRNA-5p was observed in saliva samples obtained after transplantation. Conclusions: Altogether, these data suggest that additional investigations of polyomavirus miRNA-5p in saliva should be performed shortly after renal-transplantation to evaluate the potential role in early viral reactivation.

Nonadherence to Immunosuppressive Medications Following Pediatric Kidney Transplantation Within Full Cost Coverage Health System: Prevalence and Correlates.

OBJECTIVES: Pediatric patients are at higher risk of nonadherence to immunosuppressive medication after kidney transplant and the resulting adverse outcomes. Factors associated with nonadherence vary, which follow an epidemiological framework and according to health system patterns. The Brazilian public health system covers all costs of kidney transplant, including immunosuppressive medications. We aimed to assess the prevalence and correlates of nonadherence to immunosuppressive medications in a pediatric kidney transplant population who received free access to immunosuppressive medications within the health care system. MATERIALS AND METHODS: In this single-center crosssectional study, we studied a convenience sample of 156 outpatients (< 18 years old) who were a minimum of 4 weeks posttransplant. Implementation nonadherence to immunosuppressive medications was measured by the 4 questions of the Basel Assessment of Adherence to Immunosuppressive Medications Scale. Multilevel correlates to non - adherence (patient, micro, and macro levels) were assessed. RESULTS: In our patient population, 61% were males, mean age was 13.6 ± 3.1 years, 77% were adolescents, and 84% received organs from deceased donors. We found that 33% were nonadherent to immuno - suppressive medications, mainly in timing (25%) and taking (10.9%) dimensions. Being an adolescent (odds ratio: 2.66; CI, 1.02-6.96), religion other than Catholic or Protestant (odds ratio: 4.33; CI, 1.13-16.67), and family income higher than 4 reference wages (odds ratio: 3.50; CI, 1.14-10.75) were factors associated with nonadherence. CONCLUSIONS: In our patient population of mostly adolescents, one-third displayed nonadherence to immunosuppressants. Unexpectedly, a higher economic profile, potentially representing better previous access to health care, was independently associated with nonadherence. This result highlights the need for identifying specific correlates to non - adherence before designing interventions.

Poor oral health status and short-term outcome of kidney transplantation.

AIMS: This study aims to know whether poor oral health increases the risk of acute rejection and hospitalization in kidney allograft recipients. METHODS AND RESULTS: This is a prospective cohort study. The same dentist followed participants for 2 months after renal transplant for monitoring oral health (clinical evaluation, DTMF index, and CPITN index), signs of graft rejection, infection, and hospitalization. We compiled rates and reasons for hospital readmission or extended hospital stay. The CPITN had a mean score of 0.38 ± 0.71, increasing to 0.90 ± 0.84, 60 days after transplant (P < .001). No one rejected the graft in the period of study. Patients with older age (P = .009; OR: 1.07; CI 95% 1.01-1.12) were at higher risk of hospitalization at each year of age and patients presenting pretransplant dental focus (P = .001; OR: 7.23; CI 95% 2.13-24.56) had 7.23 times more chance to be hospitalized in the first 2 months after the transplant. One participant was hospitalized due to acute foci of dental infection. CONCLUSION: There was an association between dental focus and hospital readmission/stay. However, our methods do not provide conclusive proof of causality. Hospitalization due to acute dental infection was rare.

Early Hospital Readmission (EHR) in kidney transplantation: a review article / Readmissão Hospitalar Precoce no transplante renal: artigo de revisão

Abstract Early hospital readmission (EHR), defined as all readmissions within 30 days of initial hospital discharge, is a health care quality measure. It is influenced by the demographic characteristics of the population at risk, the multidisciplinary approach for hospital discharge, the access, coverage, and comprehensiveness of the health care system, and reimbursement policies. EHR is associated with higher morbidity, mortality, and increased health care costs. Monitoring EHR enables the identification of hospital and outpatient healthcare weaknesses and the implementation of corrective interventions. Among kidney transplant recipients in the USA, EHR ranges between 18 and 47%, and is associated with one-year increased mortality and graft loss. One study in Brazil showed an incidence of 19.8% of EHR. The main causes of readmission were infections and surgical and metabolic complications. Strategies to reduce early hospital readmission are therefore essential and should consider the local factors, including socio-economic conditions, epidemiology and endemic diseases, and mobility.

Resumo A Readmissão Hospitalar Precoce (RH), definida como todas as readmissões dentro de 30 dias após a alta hospitalar inicial, é uma métrica da qualidade hospitalar. É influenciada pelas características demográficas da população em risco, pela abordagem multidisciplinar da alta hospitalar inicial, pelo acesso, pela cobertura e pela abrangência do Sistema de Saúde e pelas políticas de reembolso. A readmissão hospitalar precoce está associada a maior morbidade, mortalidade e aumento dos custos com saúde. O monitoramento da RH permite a identificação das fragilidades hospitalares e ambulatoriais e a implementação de intervenções corretivas. Entre os receptores de transplante renal nos EUA, a RH varia entre 18% e 47% e está associada a maior mortalidade e perda do enxerto no primeiro ano do transplante. Um estudo no Brasil mostrou uma incidência de 19,8% de RH. As principais causas de readmissão foram infecções e complicações cirúrgicas e metabólicas. As estratégias para reduzir a readmissão hospitalar precoce são, portanto, essenciais e devem considerar o ambiente local, incluindo condições socioeconômicas, epidemiologia local, doenças e mobilidade endêmicas.

Herpesviruses oral shedding and viremia in renal transplant recipients: A longitudinal study.

BACKGROUND: The objective was to assess the oral shedding and viremia of human herpesviruses in renal transplant recipients. METHODS: This is a cohort study in which the participants were examined in three different periods: the first within 24 hours before renal transplantation and the second and third ones 15-20 and 45-60 days after the transplantation. Mouthwash and blood samples were collected in each period and then submitted to screening for the presence of eight types of human herpesviruses by using multiplex PCR. RESULTS: HSV-1 and EBV were more frequent in the saliva after renal transplantation, 15- to 20-day period after the transplant. EBV was found in the saliva of 26 (35.6%) patients before renal transplantation and in 56.2% and 46.6% of them, in the 15- to 20-day and 45- to 60-day periods after the transplant, respectively. High detection rates (75.3%-78.1%) were found for HHV-7 despite the lack of significant variations between the study periods. There was no concordance between herpesviruses oral shedding and viremia. CONCLUSION: We concluded that the pattern of excretion of HSV-1 and EBV in saliva is changed immediately after renal transplantation, increasing in the 15- to 20-day period after the transplant surgery. No concordance between herpesviruses oral shedding and viremia was observed.

Early Hospital Readmission (EHR) in kidney transplantation: a review article.

Early hospital readmission (EHR), defined as all readmissions within 30 days of initial hospital discharge, is a health care quality measure. It is influenced by the demographic characteristics of the population at risk, the multidisciplinary approach for hospital discharge, the access, coverage, and comprehensiveness of the health care system, and reimbursement policies. EHR is associated with higher morbidity, mortality, and increased health care costs. Monitoring EHR enables the identification of hospital and outpatient healthcare weaknesses and the implementation of corrective interventions. Among kidney transplant recipients in the USA, EHR ranges between 18 and 47%, and is associated with one-year increased mortality and graft loss. One study in Brazil showed an incidence of 19.8% of EHR. The main causes of readmission were infections and surgical and metabolic complications. Strategies to reduce early hospital readmission are therefore essential and should consider the local factors, including socio-economic conditions, epidemiology and endemic diseases, and mobility.

Severe Strongyloides stercoralis infection in kidney transplant recipients: A multicenter case-control study.

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/PRINCIPAL FINDINGS: This was a retrospective, multicenter, case-control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5-965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05-18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2-7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001-1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46-2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83-35316.61). CONCLUSIONS/SIGNIFICANCE: Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment.

Clinical outcomes of incident peritoneal dialysis patients coming from kidney transplantation program: A case-control study.

INTRODUCTION: Brazil ranks second in the absolute number of transplantations in the world. Despite improvements in graft survival, many patients will progress to graft loss and return to dialysis. Concerns exist regarding adverse clinical outcomes in this population when undergone peritoneal dialysis (PD). OBJECTIVE: To compare the occurrence of mortality, technique failure, and peritonitis among incident patients in PD coming from either Tx or pre-dialysis treatment. METHODOLOGY: A retrospective study in which 47 adult patients with Tx failure (Tx group) were matched for age, gender, diabetes mellitus (DM), modality and start year of PD, with 1:1 predialysis patient (nTx group). The Fine-Gray competing risk model was used to analyze mortality and technique failure. RESULTS: Compared to nTx, the Tx group had a lower body mass index, serum potassium, and albumin concentrations. A higher ferritin level, transferrin saturation and the number of patients with positive serology for viral hepatitis were also observed in the Tx group. In the multivariate analysis, patients of the Tx group had 4.4-times higher risk of death (p = 0.007), with infection as the main cause. Technique failure and peritonitis were similar in both groups. CONCLUSION: Previous Tx is a risk factor for mortality but not for technique failure or peritonitis in incident patients on a PD program.

Severe Strongyloides stercoralis infection in kidney transplant recipients: a multicenter case-control study

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/Principal findings This was a retrospective, multicenter, case­control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5­965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05­18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2­7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001­1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46­2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83­35316.61). CONCLUSIONS/Significance Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment. (AU)

Oral manifestations of allograft recipients immediately before and after kidney transplantation.

Objective: To identify the oral lesions of individuals with kidney disease immediately before and shortly after kidney transplantation, taking into account the immunosuppressive regimen, antiviral prophylaxis and type of transplantation.Methods: A prospective observational cohort study was carried from January 2017 to January 2018. Eighty individuals aged 18 years or older who were admitted for kidney transplantation were eligible to participate. Clinical data regarding medical history, immunosuppressive therapy, antiviral prophylaxis, laboratorial data and oral examination were performed by the same trained researcher, in three different moments: 24 hours before transplantation (1st time point), 15-20 days (2nd time point) and 45-60 days (3rd time point) after transplantation.Results: In the first, second and third time points, it was found that 3.7% (3/80), 23.7% (18/76) and 25.7% (19/74) of the participants showed oral soft tissue lesions. Ulcers and candidiasis were the most frequent oral lesions, and they were associated with the use of everolimus (p = .005) and azathioprine (p = .034), respectively. Less patients reported xerostomia after transplantation than before (p < .001).Conclusions: Oral lesions are common in the short term after renal transplantation and are particularly related to both toxicities of immunosuppressive drugs and immunosuppression.