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1.
Clin Transplant ; 33(2): e13463, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30548935

RESUMO

In a prospective randomized controlled trial, between May 2001 and January 2003, 132 live-donor kidney transplant recipients were randomized to receive sirolimus primary immunosuppression, either in combination with low dose tacrolimus (Tac group) or in combination with mycophenolate mofetil (MMF group). We have previously reported on 2- and 5-year follow-up results, with favorable patient and graft outcomes obtained in both groups. In view of recent published reports of increased risk of inferior outcomes among sirolimus-treated patients, we herein present results of an observational extension of the previously randomized patients 15 years post-transplantation. Mortality rates were 10.8% and 3% in Tac and MMF groups respectively after mean follow-up period of 11.2-11.8 years. Comparable graft survival rates were obtained in both groups ranging from 60% to 62.7%. The (MMF) group continued to have the advantage of remaining on primary plan of immunosuppression (56.7% of patients) as well as to maintain better graft function in terms of serum creatinine level. Herein, we presented longest term published data for sirolimus-based immunosuppression among live-donor kidney transplants with favorable outcome in terms of survival and graft function.

2.
Pain Physician ; 21(2): E87-E96, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29565951

RESUMO

BACKGROUND: The most common surgical procedure for breast cancer is the modified radical mastectomy (MRM), but it is associated with significant postoperative pain. Regional anesthesia can reduce the stress response associated with surgical trauma. OBJECTIVES: Our aim is to explore the efficacy of 1 µg/kg dexmedetomedine added to an ultrasound (US)-modified pectoral (Pecs) block on postoperative pain and stress response in patients undergoing MRM. STUDY DESIGN: A randomized, double-blind, prospective study. SETTING: An academic medical center. METHODS: Sixty patients with American Society of Anesthesiologists (ASA) physical status I-II (18-60 years old and weighing 50-90 kg) scheduled for MRM were enrolled and randomly assigned into 2 groups (30 in each) to receive a preoperative US Pecs block with 30 mL of 0.25% bupivacaine only (group 1, bupivacaine group [GB]) or 30 mL of 0.25% bupivacaine plus 1 µg/kg dexmedetomidine (group II, dexmedetomidine group [GD]). The patients were followed-up 48 hours postoperatively for vital signs (heart rate [HR], noninvasive blood pressure [NIBP], respiratory rate [RR], and oxygen saturation [Sao2]), visual analog scale (VAS) scores, time to first request of rescue analgesia, total morphine consumption, and side effects. Serum levels of cortisol and prolactin were assessed at baseline and at 1 and 24 hours postoperatively. RESULTS: A significant reduction in the intraoperative HR, systolic blood pressure (SBP), and diastolic blood pressure (DBP) starting at 30 minutes until 120 minutes in the GD group compared to the GB group (P < 0.05) was observed. The VAS scores showed a statistically significant reduction in the GD group compared to the GB group, which started immediately up until 12 hours postoperatively (P < 0.05). There was a delayed time to first request of analgesia in the GD group (25.4 ± 16.4 hrs) compared to the GB group (17 ± 12 hrs) (P = 0.029), and there was a significant decrease of the total amount of morphine consumption in the GD group (9 + 3.6 mg) compared to the GB group (12 + 3.6 mg) (P = 0.001). There was a significant reduction in the mean serum cortisol and prolactin levels at 1 and 24 hours postoperative in the GD patients compared to the GB patients (P < 0.05). LIMITATIONS: This study was limited by its sample size. CONCLUSION: The addition of 1 µg/kg dexmedetomidine to an US-modified Pecs block has superior analgesia and more attenuation to stress hormone levels without serious side effects, compared to a regular Pecs block in patients who underwent MRM. KEY WORDS: Postoperative pain, dexmedetomidine, Pecs block, stress response, breast surgery.


Assuntos
Analgésicos não Entorpecentes/uso terapêutico , Dexmedetomidina/uso terapêutico , Mastectomia Radical Modificada/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Estresse Fisiológico/efeitos dos fármacos , Adolescente , Adulto , Neoplasias da Mama/cirurgia , Método Duplo-Cego , Feminino , Humanos , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estudos Prospectivos , Adulto Jovem
3.
Transplantation ; 101(8S)Aug. 2017.
Artigo em Inglês | BIGG | ID: biblio-946796

RESUMO

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.


Assuntos
Humanos , Seleção do Doador , Nefropatias/reabilitação , Transplante de Rim , Doadores Vivos
4.
Transplantation ; 101(8): 1783-1792, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28737659

RESUMO

Kidney Disease: Improving Global Outcomes (KDIGO) engaged an evidence review team and convened a work group to produce a guideline to evaluate and manage candidates for living kidney donation. The evidence for most guideline recommendations is sparse and many "ungraded" expert consensus recommendations were made to guide the donor candidate evaluation and care before, during, and after donation. The guideline advocates for replacing decisions based on assessments of single risk factors in isolation with a comprehensive approach to risk assessment using the best available evidence. The approach to simultaneous consideration of each candidate's profile of demographic and health characteristics advances a new framework for assessing donor candidate risk and for defensible shared decision making.


Assuntos
Consenso , Doadores Vivos/provisão & distribução , Nefrologia/normas , Guias de Prática Clínica como Assunto , Insuficiência Renal Crônica/cirurgia , Humanos
5.
Transplantation ; 101(8S Suppl 1): S1-S109, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28742762

RESUMO

The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.


Assuntos
Nefropatias/cirurgia , Transplante de Rim/normas , Doadores Vivos , Assistência Perioperatória/normas , Humanos
6.
Clin J Pain ; 32(10): 889-97, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-26710216

RESUMO

OBJECTIVES: Analgesics had been suspected of impairing various immune functions either directly or indirectly. Our primary objective was to compare the effects of intravenous (IV) morphine, tramadol, and ketorolac on stress and immune responses in patients who underwent modified radical mastectomy. PATIENTS: Sixty patients randomly assigned to receive IV morphine 5 mg (group M, n=20), tramadol 100 mg (group T, n=20), or ketorolac 60 mg (group K, n=20) at the end of surgery. METHODS: Serum cortisol, prolactin were measured immediately, 40 minutes, and 24 hours postoperatively. Expressions of peripheral T lymphocytes (CD3, CD3CD4, CD3CD8) and natural killer cells (CD3, CD56) were measured as percentages of total lymphocytes by flow cytometry immediately, 90 minutes, and 24 hours postoperatively. RESULTS: After 40 minutes, cortisol level increased but prolactin decreased significantly (P=0.001), then both decreased after 24 hours (P=0.001) compared with baseline within the 3 groups. CD3, CD4, CD8, and CD56 significantly decreased at 90 minutes and 24 hours (P≤0.033) compared with baseline in the 3 groups. CD4, CD8, and CD56 significantly decreased in group M, compared with group T and K (P≤0.016) and CD3, CD8, and CD56 in group T compared with group K at 90 minutes (P≤0.024) postoperatively. After 24 hours, CD4, and CD8 decreased in group M compared with group T (P≤0.048) and CD4 and CD56 in groups M and T compared with group K (P≤0.049). CONCLUSIONS: IV morphine, tramadol, and ketorolac suppressed stress and immune responses. Ketorolac was the least immunosuppressive among the 3 drugs.


Assuntos
Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Cetorolaco/uso terapêutico , Mastectomia Radical Modificada , Morfina/uso terapêutico , Tramadol/uso terapêutico , Administração Intravenosa , Adulto , Humanos , Hidrocortisona/sangue , Células Matadoras Naturais/efeitos dos fármacos , Células Matadoras Naturais/imunologia , Pessoa de Meia-Idade , Dor Pós-Operatória/sangue , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios , Prolactina/sangue , Linfócitos T/efeitos dos fármacos , Linfócitos T/imunologia , Resultado do Tratamento , Adulto Jovem
7.
Transplantation ; 100(8): 1776-84, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26528771

RESUMO

BACKGROUND: Many nations are able to prosecute transplant-related crimes committed in their territory, but transplant recipients, organ sellers and brokers, and transplant professionals may escape prosecution by engaging in these practices in foreign locations where they judge the risk of criminal investigation and prosecution to be remote. METHODS: The Declaration of Istanbul Custodian Group convened an international working group to evaluate the possible role of extraterritorial jurisdiction in strengthening the enforcement of existing laws governing transplant-related crimes across national boundaries. Potential practical and ethical concerns about the use of extraterritorial jurisdiction were examined, and possible responses were explored. RESULTS: Extraterritorial jurisdiction is a legitimate tool to combat transplant-related crimes. Further, development of a global registry of transnational transplant activities in conjunction with a standardized international referral system for legitimate travel for transplantation is proposed as a mechanism to support enforcement of national and international legal tools. CONCLUSIONS: States are encouraged to include provisions on extraterritorial jurisdiction in their laws on transplant-related crimes and to collaborate with professionals and international authorities in the development of a global registry of transnational transplant activities. These actions would assist in the identification and evaluation of illicit activities and provide information that would help in developing strategies to deter and prevent them.


Assuntos
Política de Saúde/legislação & jurisprudência , Cooperação Internacional , Turismo Médico/legislação & jurisprudência , Tráfico de Órgãos/prevenção & controle , Transplante de Órgãos/legislação & jurisprudência , Formulação de Políticas , Doadores de Tecidos/legislação & jurisprudência , Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Imperícia/legislação & jurisprudência , Turismo Médico/ética , Tráfico de Órgãos/ética , Tráfico de Órgãos/legislação & jurisprudência , Transplante de Órgãos/ética , Papel do Médico , Má Conduta Profissional/legislação & jurisprudência , Sistema de Registros , Doadores de Tecidos/ética , Doadores de Tecidos/provisão & distribução , Revelação da Verdade
8.
Exp Clin Transplant ; 13(1): 26-34, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25654411

RESUMO

OBJECTIVES: New-onset diabetes mellitus after transplant is a common complication in renal allograft recipients. Recently, a high prevalence of diabetes mellitus has been reported in patients with chronic hepatitis C virus. The association between hepatitis C and diabetes mellitus is well demonstrated in the general population, but some controversy still exists. This work aimed to study the effect of pretransplant hepatitis C virus on the development of new-onset diabetes mellitus after transplant in Egyptian living-donor renal allotransplant recipients. MATERIALS AND METHODS: This retrospective single center study included 913 kidney transplant recipients who were transplanted at Mansoura Urology and Nephrology Center between 2000 and 2010. The patients were divided into 4 groups according to their hepatitis C virus serology and diabetic status. RESULTS: Pretransplant dialysis duration and number of blood transfusion units were statistically significant among both viremic and nonviremic groups. With respect to induction therapy, a highly statistical significance was observed between the 4 groups regarding presence and type of adjuvant therapy (P < .001). With respect to maintenance immunosuppression, high statistically significant results were observed regarding steroid and rapamycin between the 4 groups (P < .001) with lower significance regarding mycophenolate mofetil (P = .04) but no significance regarding azathioprine, cyclosporine, or tacrolimus therapy. Incidence of new-onset diabetes mellitus after transplant was statistically higher in the viremic than nonviremic group (P < .001). CONCLUSIONS: There was a positive correlation between incidence of new-onset diabetes mellitus after transplant and positive pretransplant hepatitis C virus status.


Assuntos
Diabetes Mellitus/etiologia , Hepacivirus/patogenicidade , Hepatite C/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Doadores Vivos , Adolescente , Adulto , Biomarcadores/sangue , Diabetes Mellitus/sangue , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/virologia , Egito , Feminino , Sobrevivência de Enxerto , Hepatite C/sangue , Hepatite C/diagnóstico , Hepatite C/virologia , Humanos , Imunossupressores/uso terapêutico , Falência Renal Crônica/complicações , Falência Renal Crônica/diagnóstico , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
9.
Biomed Res Int ; 2013: 912413, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23878820

RESUMO

INTRODUCTION: The aim of this report is to study the graft and patient survival in a large cohort of recipients with an analysis of factors that may affect the final outcomes. METHODS: Between March 1976 and March 2008, 1967 consecutive live-donor renal transplants were carried out. Various variables that may have an impact on patients and/or graft survival were studied in two steps. Initially, a univariate analysis was carried out. Thereafter, significant variables were embedded in a stepwise regression analysis. RESULTS: The overall graft survival was 86.7% and 65.5%, at 5 and 10 years, respectively. The projected half-life for grafts was 17.5 years and for patients was 22 years. Five factors had an independent negative impact on graft survival: donor's age, genetic considerations, the type of primary immunosuppression, number of acute rejection episodes, and total steroid dose during the first 3 months after transplantation. CONCLUSIONS: Despite refinements in tissue matching techniques and improvements in immunosuppression protocols, an important proportion of grafts is still lost following living donor kidney transplantation, presumably due to chronic allograft nephropathy.


Assuntos
Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Transplante de Rim/mortalidade , Doadores Vivos/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Egito/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
10.
Transplantation ; 92(10): 1123-8, 2011 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-21956203

RESUMO

BACKGROUND: Renal tumors are common in the pretransplant end-stage renal disease population. Their impact on transplant outcome has not been well addressed. METHODS: This study is a retrospective follow-up observational study conducted in 258 renal transplant recipients. All patients had an ipsilateral native nephrectomy at the time of transplantation. We reviewed the histopathology of all native nephrectomies to gauge the prevalence of renal cell carcinoma (RCC) and to investigate the impact of accidental discovery of RCC on graft and patient outcome. RESULTS: RCC was found in 12 patients (4.7%): clear type in 9 patients, and chromophobe and combined clear and papillary type in 1 and 2 patients, respectively. There was no significant difference in human leukocyte antigen mismatch, primary immunosuppression, occurrence of rejection, graft function, and patient and graft survival between patients with or without RCC. RCC presented in the other native kidney in three patients (25%) posttransplantation and one of them developed metastasis 4 years after renal transplantation in the RCC group in comparison with eight patients in the control group (3.3%; P<0.001). The median follow-up period was 56 months for the RCC group and 65 months for the control group. CONCLUSIONS: We found that renal transplant outcome and patient survival were not adversely affected by the presence of accidently discovered RCC at the time of transplantation. These patients seem to be at significantly higher risk of the occurrence of RCC in the remaining native kidney. Further studies are warranted to confirm our results.


Assuntos
Carcinoma de Células Renais/complicações , Sobrevivência de Enxerto , Neoplasias Renais/complicações , Transplante de Rim/mortalidade , Adulto , Idoso , Carcinoma de Células Renais/patologia , Feminino , Humanos , Falência Renal Crônica/complicações , Neoplasias Renais/patologia , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
Exp Clin Transplant ; 9(4): 247-51, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21819369

RESUMO

OBJECTIVES: The effect of basiliximab induction therapy on long-term patient and graft survival is not clear. We sought to evaluate if there is any advantage to routine basiliximab induction on the long-term outcome of living-related donor kidney transplants. MATERIALS AND METHODS: One hundred adult recipients with their first kidney allograft were randomized into 2 treatment groups; 1 group received basiliximab, and the second served as a control. All patients received a maintenance triple immunosuppressive therapy (steroids, cyclosporine, microemulsion, and azathioprine). We followed them for 10 years. RESULTS: Basiliximab reduced the proportion of patients who experienced an acute rejection in the first year (18/50) when compared with the control group (31/50) (P = .009), and in 10 years (28/50) when compared with controls (37/50) (P = .059). The cumulative steroid dosage used throughout the study was significantly lower in the basiliximab group. The overall incidence of posttransplant complications was comparable among the 2 groups. There was no significant difference in patient and graft survival; 10-year patient and graft survival were 92% and 76% for basiliximab and 90% and 68% for the control group. CONCLUSIONS: Routine basiliximab induction significantly reduces the incidence of acute rejection without any noticeable effects on the long-term renal transplant outcome.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Imunossupressores/uso terapêutico , Transplante de Rim , Doadores Vivos , Proteínas Recombinantes de Fusão/uso terapêutico , Adulto , Basiliximab , Distribuição de Qui-Quadrado , Quimioterapia Combinada , Egito , Feminino , Rejeição de Enxerto/imunologia , Humanos , Estimativa de Kaplan-Meier , Transplante de Rim/imunologia , Masculino , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
12.
Exp Clin Transplant ; 9(2): 121-7, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21453230

RESUMO

OBJECTIVES: Steroids have had the main role in renal transplant for more than 4 decades. However, chronic use of steroids is associated with many comorbidities, owing to a lack of assessing cost-benefit of steroid avoidance in live-donor renal allotransplants. In this prospective, randomized, controlled study, we aimed to assess the cost-benefit of a steroid-free immunosuppression regimen among Egyptian live-donor renal transplants. MATERIALS AND METHODS: One hundred patients were randomly allocated to receive tacrolimus, mycophenolate mofetil, and steroids for only 3 days (n=50 patients; study group) or tacrolimus, mycophenolate mofetil, and steroids on a maintenance basis (n=50 patients; control group). All patients received basiliximab (Simulect) induction, with median follow-up of 12 months. RESULTS: Both groups showed comparable graft and patient survivals, rejection episodes, and graft functioning. Posttransplant comorbidities were significantly more prevalent in the steroid-maintenance group. Hypertension was detected in 4% of steroid-free group versus 24% in the steroid-maintenance group (P = .0009). Posttransplant diabetes mellitus, serious infections, and hyperlipidemia were significantly more prevalent in the steroid-maintenance group (P < .05). Associated hospitalization costs were 2.2-fold higher in the steroid-maintenance group than they were in the steroid-free group. One year after transplant, the cost of managing posttransplant comorbidities was significantly higher in steroid-maintenance group, despite comparable costs of immunosuppression. CONCLUSIONS: In low, immunologic risk recipients of live-donor renal transplants, using basiliximab induction and maintenance with tacrolimus, mycophenolate mofetil, steroid avoidance was associated with lower first annual total costs despite comparable immunosuppression costs, which was attributed to lower costs of associated morbidities.


Assuntos
Diabetes Mellitus/epidemiologia , Hiperlipidemias/epidemiologia , Hipertensão/epidemiologia , Imunossupressão/economia , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Doadores Vivos , Esteroides , Adolescente , Adulto , Anticorpos Monoclonais/uso terapêutico , Basiliximab , Comorbidade , Contraindicações , Análise Custo-Benefício , Diabetes Mellitus/economia , Diabetes Mellitus/etiologia , Feminino , Rejeição de Enxerto/epidemiologia , Humanos , Hiperlipidemias/economia , Hiperlipidemias/etiologia , Hipertensão/economia , Hipertensão/etiologia , Imunossupressão/métodos , Incidência , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Estudos Prospectivos , Proteínas Recombinantes de Fusão/uso terapêutico , Esteroides/efeitos adversos , Esteroides/uso terapêutico , Tacrolimo/uso terapêutico , Transplante Homólogo , Resultado do Tratamento , Adulto Jovem
13.
Exp Clin Transplant ; 8(4): 283-91, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21143093

RESUMO

OBJECTIVES: Recent evidence of a high incidence of proteinuria among de novo sirolimus-based regimens has been reported among renal transplant patients at short-term follow-up. We report on long-term evaluation of proteinuria among patients maintained on such regimen. MATERIALS AND METHODS: Between May 2001 and January 2003, 132 patients received a renal allograft from a living donor and were randomized to 2 groups (steroids/sirolimus/tacrolimus, n=65) and (steroids/sirolimus/mycophenolate mofetil, n=67): Both received basiliximab induction. Retrospective review of those patients was performed, 5 years posttransplant with particular emphasis on the incidence of proteinuria. RESULTS: The 5-year incidence of proteinuria was 29.2% and 38.8% among sirolimus/tacrolimus and sirolimus/mycophenolate mofetil group. Single DR-matched patients (P = .016) and the incidence of acute rejection (P = .039) were associated with significantly higher incidence of proteinuria. Moreover, the presence of mesangial matrix increased (P = .015), and glomerulosclerosis (P = .014), in 1-year protocol biopsies, was found to have a positive predictive value for current and future incidences of proteinuria. Proteinuria was found to be associated with significant inferior graft outcome. Recurrent original kidney disease, de novo glomerulopathy, and acute transplant glomerulopathy were responsible for early cases of nephrotic range proteinuria (first 2 years), while cases presented later were attributed to chronic allograft nephropathy. CONCLUSIONS: Proteinuria has become a recognized, serious event of primarily sirolimus-treated renal transplants patients, which is most probably of glomerular origin. It has been shown that proteinuria exerts a bad prognostic effect upon graft function and subsequent graft survival at 5-year follow-up.


Assuntos
Imunossupressores/efeitos adversos , Transplante de Rim/efeitos adversos , Doadores Vivos , Proteinúria/etiologia , Sirolimo/efeitos adversos , Adulto , Biópsia , Distribuição de Qui-Quadrado , Quimioterapia Combinada , Egito , Feminino , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto/efeitos dos fármacos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Ácido Micofenólico/efeitos adversos , Ácido Micofenólico/análogos & derivados , Proteinúria/epidemiologia , Proteinúria/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Esteroides/efeitos adversos , Tacrolimo/efeitos adversos , Fatores de Tempo , Transplante Homólogo , Resultado do Tratamento , Adulto Jovem
14.
Scand J Urol Nephrol ; 44(3): 175-82, 2010 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-20230185

RESUMO

OBJECTIVE: Steroids have played a major role in renal transplantation for more than four decades. However, chronic use of steroids is associated with a lot of comorbidities. This study aimed to assess the cost-benefit of steroid-free immunosuppression regimen in a prospective randomized controlled study of live donor renal transplantation, which was lacking in the literature. MATERIAL AND METHODS: One-hundred patients were randomized to receive tacrolimus (Tac), mycophenolate mofetil (MMF), basiliximab (Simulect) induction and steroids only for 3 days (50 patients, study group) or Tac, MMF, Simulect induction and steroid maintenance (50 patients, control group). Median follow-up was 12 months. RESULTS: Both groups showed comparable graft and patient survival, rejection episodes and graft function. Post-transplant hypertension was detected in 4% of the steroid-free group and 24% of the steroid maintenance group (p = 0.0009), while post-transplant diabetes mellitus was detected in 4% and 16% of these two groups, respectively (p = 0.037). By the end of the first year, the cost of managing post-transplant morbidities was significantly higher in the steroid maintenance group, despite the comparable cost of immunosuppression. CONCLUSIONS: Among low immunological risk recipients of live donor renal transplants, steroid avoidance was feasible, safe and with less morbidity, using Simulect induction, and tacrolimus and MMF as maintenance immunosuppression. Steroid avoidance was associated with a lower total cost despite comparable immunosuppression cost, which was attributed to the lower cost of associated morbidities.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Imunossupressão/economia , Imunossupressores/uso terapêutico , Transplante de Rim , Ácido Micofenólico/análogos & derivados , Proteínas Recombinantes de Fusão/uso terapêutico , Esteroides/uso terapêutico , Tacrolimo/uso terapêutico , Adulto , Basiliximab , Análise Custo-Benefício , Feminino , Humanos , Imunossupressão/métodos , Masculino , Ácido Micofenólico/uso terapêutico , Estudos Prospectivos
15.
Nephrol Dial Transplant ; 25(1): 274-7, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19767633

RESUMO

BACKGROUND: Nail changes are common complications of end-stage renal disease, and reports of nail changes in kidney transplant recipients (KTR) are rare. Few reports have documented a higher prevalence of onychomycosis in KTR compared with controls, while others found no significant differences. In this study, we investigated the prevalence and nature of nail changes in a large series of KTR. METHODS: Three hundred and two KTR (216 males and 86 females) were included in this study, and the mean transplant duration was 6.57 years (range 1.5 month-23 years). They were screened for the presence of nail changes. Nail clippings were collected when indicated and cultures were performed for patients with suspected onychomycosis. The patients were compared with 302 age- and sex-matched healthy controls (220 males and 82 females). RESULTS: One hundred and twenty-one KTR (40.1%) had nail changes compared with 104 (34.4%) in controls. Onychomycosis, Muehrcke's nail and leuconychia were significantly more common in KTR [23 (7.6%), 13.3 (4.3%), 11 (3.6%), respectively] compared with controls [7 (2.3%), 1(0.3%), 2 (0.66%), P = 0.002, 0.001 and 0.02, respectively]. However, the most frequent nail change among KTR and controls was absent lunula, 90 (29.8%) and 80 (26.5%), respectively P = 0.36. Longitudinal ridging was also a frequent nail pathology among KTR and controls, 21 (6.9%) and 19 (6.3%), respectively, P = 0.74. CONCLUSION: KTR have higher prevalence rates of onychomycosis, Muehrcke's nail and leuconychia than the healthy population. On the other hand, absent lunula could be a normal variation among Egyptian people.


Assuntos
Dermatoses da Mão/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim , Onicomicose/epidemiologia , Adolescente , Adulto , Estudos de Casos e Controles , Criança , Egito/epidemiologia , Feminino , Dermatoses da Mão/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças da Unha/epidemiologia , Doenças da Unha/patologia , Unhas/patologia , Onicomicose/patologia , Prevalência , Adulto Jovem
16.
Clin Exp Nephrol ; 13(2): 161-165, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19153804

RESUMO

INTRODUCTION: ABO compatible non-identical kidney transplants are used frequently. Acquired hemolytic anemia has been reported after ABO mismatched transplantation. Patients of A, B or AB blood groups may receive organs from ABO-compatible, but non-identical donors, mostly from O blood group donors. It may also occur in patients of the AB blood group who receive a kidney from a donor of the A or B blood groups. PATIENTS AND METHODS: ABO non-identical living donor kidney transplantation was done in 214 cases. All studied patients received kidneys from one haplotype HLA mismatched living donors and had pretransplant non-specific blood transfusions. There were 164 males and 50 females with a mean age of 30 years. Ten patients with cyclosporine (CsA)-based therapy developed hemolysis. CsA was stopped in patients maintained on triple immunosuppression (pred, CsA, AZA) and shifted to azathioprine in patients maintained on pred CsA therapy. In all patients pretransplant antibody screen, direct antiglobulin test (DAT) and cytotoxic cross match were all negative. RESULTS: The prognosis was excellent in nine patients, and one died from severe hemolysis. Hemolytic anemia was more frequent among blood group A recipients (60% of our cases) and more severe among recipient blood group B. Six patients received antigen-negative packed RBCs. Univariate analysis demonstrated significant impact for recipient age, donor sex, number of pretransplant blood transfusions, primary immunosuppression, time to onset of diuresis, recipient and donor blood groups. Multivariate analysis restricted the significance to blood group of donor and recipient, time to onset of diuresis and primary immunosuppression. CONCLUSIONS: Post transplant hemolysis is infrequent after renal transplantation; however, it may occur with compatible, non-identical ABO blood group donors. Blood group of donor and recipient, time to onset of diuresis and primary immunosuppression (mainly CsA) were significant risk factors in hemolytic anemia in patients after ABO non-identical living donor kidney transplantation. The condition is usually mild and self limited, and change of immunosuppression (stop CsA) can treat the condition.


Assuntos
Sistema do Grupo Sanguíneo ABO/imunologia , Anemia Hemolítica/etiologia , Anemia Hemolítica/imunologia , Transplante de Rim/efeitos adversos , Transplante de Rim/imunologia , Adolescente , Adulto , Anemia Hemolítica/epidemiologia , Tipagem e Reações Cruzadas Sanguíneas , Criança , Pré-Escolar , Feminino , Rejeição de Enxerto/tratamento farmacológico , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/imunologia , Humanos , Imunossupressores/uso terapêutico , Transplante de Rim/estatística & dados numéricos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Adulto Jovem
17.
Saudi J Kidney Dis Transpl ; 19(4): 564-70, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18580014

RESUMO

Chronic allograft nephropathy (CAN) remains a major cause of graft failure over the long term, second only to patient mortality. The main adverse effects of cyclosporine A (CsA) include nephrotoxicity, hypertension, symptomatic hyperuricemia, hirsutism, and gum hyperplasia. Available studies among live related donor renal transplants lack adequate information regarding the long-term efficacy and safety of primary CsA-based immunosuppressive regimens. This prospective randomized study is aimed at evaluating the long-term results of CsA-based immunosuppressive protocols in live-donor kidney transplantation. The follow-up data of 444 renal transplant recipients operated at the Urology and Nephrology Center, Mansoura University, prior to 1996 were reviewed. Primary immuno-suppressive protocols included: steroids and azathioprine (group I, 130 cases); steroids and CsA (group II, 75 cases); and steroids, CsA, and azathioprine (group III, 239 cases). Only adult primary renal transplant recipients with age ranging between 18 and 60 years and one haplotype HLA mismatch with the donor were included. All patients received kidneys from living related donors with previous donor non-specific blood transfusions. The percentage of cases with chronic rejection was significantly higher in group III. Living cases with graft failure were significantly higher in group III, whereas mortality was significantly higher in group I. Diabetic patients and those with serious bacterial infections were significantly more prevalent in group II. Hypertensive patients were significantly more common in groups I and II. Liver disease was more prevalent among patients in group III. Our study suggests that the long-term results of treatment with steroids and azathioprine are satisfactory in live related donor kidney transplant recipients. Chronic rejection was significantly higher in patients in group III, possibly due to the risk of CsA nephrotoxicity. Groups with CsA-based protocols experienced many adverse reactions of CsA such as hypertension, diabetes mellitus, and chronic rejection.


Assuntos
Azatioprina/uso terapêutico , Ciclosporina/uso terapêutico , Transplante de Rim/imunologia , Doadores Vivos , Corticosteroides/uso terapêutico , Adulto , Quimioterapia Combinada , Egito , Feminino , Sobrevivência de Enxerto/imunologia , Humanos , Imunossupressores/uso terapêutico , Nefropatias/classificação , Nefropatias/cirurgia , Transplante de Rim/mortalidade , Masculino , Estudos Retrospectivos , Análise de Sobrevida
18.
J Am Soc Nephrol ; 19(6): 1225-32, 2008 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-18337483

RESUMO

Calcineurin inhibitor (CNI) nephrotoxicity is a major concern after renal transplantation. To investigate the safety and efficacy of a CNI-free immunosuppressive regimen, 132 live-donor renal transplant recipients were included in a prospective, randomized controlled trial. All patients received induction therapy with basiliximab and steroids. The patients were randomized to a maintenance immunosuppression regimen that included steroids, sirolimus, and either low-dose tacrolimus or mycophenolate mofetil (MMF). Over a mean follow-up period of approximately 5 yr, patient and graft survival did not significantly differ between the two maintenance regimens. Patient survival was 93.8% and 98.5% in the tacrolimus/sirolimus and MMF/sirolimus groups, respectively, and graft survival was 83% and 88%, respectively. However, the MMF/sirolimus group had significantly better renal function, calculated by Cockcroft-Gault, from the second year post-transplant until the last follow-up. In addition, this group was less likely to require a change in their primary immunosuppression regimen than the tacrolimus/sirolimus group (20.8% versus 53.8%, P = 0.001). The safety profile was similar between groups. In summary, after long-term follow-up, a CNI-free maintenance regimen consisting of sirolimus, MMF, and steroids was both safe and efficacious among low to moderate immunologic risk renal transplant recipients.


Assuntos
Calcineurina , Imunossupressão/métodos , Imunossupressores/uso terapêutico , Transplante de Rim , Ácido Micofenólico/análogos & derivados , Sirolimo/uso terapêutico , Tacrolimo/uso terapêutico , Proteínas Adaptadoras de Transdução de Sinal , Seguimentos , Humanos , Doadores Vivos , Ácido Micofenólico/uso terapêutico , Estudos Prospectivos , Fatores de Tempo
19.
Clin Exp Nephrol ; 12(5): 376-381, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18327678

RESUMO

BACKGROUND/AIMS: The effect of basiliximab induction therapy on long-term patient and graft survival is not yet clear. We aimed to evaluate if there is any advantage of routine basiliximab induction on the long-term outcome of living related donor kidney transplantation. METHODS: One hundred adult recipients with their first kidney allograft were randomized into two treatment groups, one group received basiliximab and the second served as a control. All patients received a maintenance triple immunosuppressive therapy (steroids, cyclosporine (CsA) micro-emulsion and azathioprine) and were followed up thoroughly for 7 years. RESULTS: Basiliximab significantly reduced the proportion of patients who experienced acute rejection in the first year (18/50) when compared to the control group (31/50), and in 7 years (28/50) when compared to (37/50) in controls. The cumulative steroid dose used throughout the whole study period was significantly lower in the basiliximab group. The overall incidence of post-transplant complications was comparable among the two treatment groups. There was no significant difference in patient or graft survival; 7 years patient and graft survival were 92, 76% for basiliximab and 92, 80% for the control group, respectively. CONCLUSION: Routine basiliximab induction significantly reduced the incidence of acute rejection without any noticeble beneficial effect on the long-term renal transplantation outcome.


Assuntos
Anticorpos Monoclonais/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Transplante de Rim , Doadores Vivos , Proteínas Recombinantes de Fusão/uso terapêutico , Adulto , Anticorpos Monoclonais/efeitos adversos , Azatioprina/uso terapêutico , Basiliximab , Ciclosporina/uso terapêutico , Feminino , Seguimentos , Humanos , Imunossupressores/efeitos adversos , Transplante de Rim/imunologia , Estudos Longitudinais , Masculino , Estudos Prospectivos , Proteínas Recombinantes de Fusão/efeitos adversos , Esteroides/uso terapêutico , Resultado do Tratamento
20.
Iran J Kidney Dis ; 2(1): 34-9, 2008 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19367007

RESUMO

INTRODUCTION: Achievements in short-term graft survival since the introduction of cyclosporine has not been matched by improvement in long-term graft function, and chronic allograft nephropathy remains the second commonest cause of graft attrition over time. We aimed to evaluate the long-term results of conventional immunosuppression by steroid and azathioprine in comparison with cyclosporine-based triple therapy in living donor kidney transplants. MATERIALS AND METHODS: We evaluated the long-term follow-up data of 369 living related kidney transplant recipients that were on prednisolone-azathioprine immunosuppressive therapy (group 1) or triple therapy by prednisolone, cyclosporine, and azathioprine (group 2). All recipients were followed-up for more than 10 years (mean, 240 +/- 12 months). Comparative analyses included patient and graft survival rates, condition at last follow-up, graft rejection, and graft function. RESULTS: There were 130 patients in group 1 and 239 in group 2. The overall frequency of acute rejection episodes was not significantly different between the two groups. However, the proportion of patients with chronic allograft nephropathy was significantly higher in group 2 (21% versus 35%, P = .001). Graft survival rates were 85.3% versus 92.4% at 1 year, 69.9% versus 71.9% at 5 years, and 52.5% versus 50.8% at 10 years in groups 1 and 2, respectively (P = .03). The two groups were comparable regarding posttransplant malignancies, diabetes mellitus, serious bacterial infections, and hepatic diseases. However, hypertensive patients were significantly more frequent in group 2. CONCLUSIONS: Chronic allograft nephropathy was significantly higher in patients receiving cyclosporine, possibly due to the risk of drug-induced nephrotoxicity, glomerular disease recurrence, and hypertension. Nowadays, it is possible to achieve excellent calcineurin inhibitors-free regimen using newer maintenance immunosuppressive agents.


Assuntos
Azatioprina/uso terapêutico , Ciclosporina/uso terapêutico , Imunossupressores/uso terapêutico , Transplante de Rim , Prednisolona/uso terapêutico , Adulto , Azatioprina/efeitos adversos , Ciclosporina/efeitos adversos , Quimioterapia Combinada , Feminino , Seguimentos , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Humanos , Hipertensão/induzido quimicamente , Imunossupressores/efeitos adversos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Prednisolona/efeitos adversos , Transplante Homólogo , Adulto Jovem
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