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1.
Cornea ; 40(1): 54-60, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32501833

RESUMO

PURPOSE: To describe the outcomes of allograft ocular surface stem cell transplantation (OSST) and the complication profile of systemic immunosuppression (SI) in pediatric patients with limbal stem cell deficiency. METHODS: This was a retrospective interventional case series from a single tertiary referral institution of 20 eyes from 13 patients who 1) underwent allograft OSST surgery, 2) were 18 years or less at time of OSST, and 3) received SI with 4) a minimum of 12-months follow-up. The main outcome measures were ocular surface stability, visual acuity, and SI adverse events. RESULTS: The mean age of patients was 15.1 ± 3.2 years (range 9-18 years). The mean follow-up was 5.6 ± 5.0 years after OSST. At the last follow-up, 15 eyes (75%) had a stable ocular surface, 1 eye (5%) developed partial failure, and 4 eyes (20%) developed total surface failure. Preoperative mean logarithm of the minimum angle of resolution visual acuity 1.5 improved to 1.1 at the last follow-up (P = 0.1); when 4 eyes of 3 nonadherent patients were excluded, the results were more pronounced and statistically significant (1.5 improved to 1.0, P = 0.002). SI was tolerated well by all patients with minimal adverse events. CONCLUSIONS: OSST provides a stable ocular surface and is a successful treatment option for pediatric patients with limbal stem cell deficiency. SI is well-tolerated with a minimal complication profile.

2.
Adv Chronic Kidney Dis ; 27(5): 434-441, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-33308510

RESUMO

Coronavirus disease 2019, the disease caused by the severe acute respiratory syndrome coronavirus 2 virus, was first identified in the Hubei Province of China in late 2019. Currently, the only role for therapy is treatment of the disease, as opposed to postexposure prophylaxis, however multiple clinical trials are currently ongoing for both treatment and prophylaxis. Treating coronavirus disease 2019 relies on two components; the first is inhibition of the viral entrance and replication within the body and the second is inhibition of an exacerbated immune response which can be seen in patients with severe disease. Many drugs have shown in vitro antiviral activity; however, clinical trials have not been as promising. This review summarizes the current data for the most commonly used drugs for coronavirus disease 2019 and will cover the unique factors that may affect the dosing of these medications in patients with CKD. While clinical trials are ongoing, most are in patients with normal kidney function. During a pandemic, when patients with CKD are at higher risk of both infection and death, it is imperative to include patients these patients in the clinical trials.


Assuntos
Anti-Inflamatórios/uso terapêutico , Antivirais/uso terapêutico , Insuficiência Renal Crônica/metabolismo , Monofosfato de Adenosina/análogos & derivados , Monofosfato de Adenosina/uso terapêutico , Alanina/análogos & derivados , Alanina/uso terapêutico , Amidas/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , /prevenção & controle , /uso terapêutico , Cloroquina/uso terapêutico , Creatinina/metabolismo , Citidina/análogos & derivados , Citidina/uso terapêutico , Dexametasona/uso terapêutico , Combinação de Medicamentos , Interações Medicamentosas , Humanos , Hidroxicloroquina/uso terapêutico , Hidroxilaminas/uso terapêutico , Imunização Passiva , Interferons/uso terapêutico , Inibidores de Janus Quinases/uso terapêutico , Lopinavir/uso terapêutico , Pirazinas/uso terapêutico , Eliminação Renal , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal , Ribavirina/uso terapêutico , Ritonavir/uso terapêutico
3.
Cornea ; 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33009096

RESUMO

PURPOSE: Panel-reactive antibody (PRA) testing has been widely adopted in solid organ transplantation for risk assessment in potential allograft recipients but has not been studied in the context of ophthalmic transplantation. The purpose of this study is to evaluate outcomes in patients undergoing ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency (LSCD) relative to preoperative PRA level. METHODS: This is retrospective chart review of all eyes with documented PRA level that underwent OSST for LSCD between May 2000 and March 2019 at a single institution. Eyes with stable ocular surface but <1 year of follow-up and eyes without updated PRA before repeat OSST were excluded. Eyes were grouped by PRA <80% and ≥80%. The primary outcome was ocular surface failure, whereas the secondary outcome was clinical allograft rejection. RESULTS: Sixty-nine surgeries met inclusion criteria, consisting of 54 living-related conjunctival limbal allografts, 5 keratolimbal allografts, and 10 combined living-related conjunctival limbal allografts/keratolimbal allografts (Cincinnati procedure). The most common etiologies for LSCD were aniridia (33%), chemical/thermal injury (28%), and contact lens associated (14%). Surface failure occurred in 5 of 12 eyes (58%) with PRA ≥80% versus 12 of 57 eyes (21%) with PRA <80% (P = 0.01). The relative risk for surface failure with PRA ≥80% was 2.8 [confidence interval (CI), 1.38-5.55]. There was no significant difference in acute rejection (P = 1). CONCLUSIONS: Pretransplant PRA level is an important prognostic factor for ocular surface stability in eyes undergoing OSST for LSCD, with implications for donor selection, perioperative management, and systemic immunosuppression.

4.
Semin Dial ; 33(3): 279-285, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32277512

RESUMO

Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.

5.
Cornea ; 39(8): 980-985, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32265383

RESUMO

PURPOSE: To compare the long-term outcomes of living-related conjunctival limbal allograft (lr-CLAL) with keratolimbal allograft (KLAL) in patients with limbal stem cell deficiency. METHODS: A retrospective, comparative, interventional cohort of patients with bilateral total limbal stem cell deficiency who underwent surgical treatment with a KLAL or lr-CLAL procedure alone (not combined with any other ocular surface stem cell transplantation procedures) with a minimum follow-up of 1 year and who received systemic immunosuppression. Ocular surface stability, best-corrected visual acuity (BCVA), and postoperative complications at the last follow-up were the main outcome measures. RESULTS: There were 224 eyes that underwent KLAL alone and 63 eyes that underwent lr-CLAL alone, with a mean follow-up time for all eyes of 7.2 years (range 1.0-16.0 years). For lr-CLAL eyes, 82.5% maintained a stable ocular surface compared with 64.7% of KLAL eyes at the last follow-up. Only 6.3% of lr-CLAL eyes demonstrated a failed ocular surface compared with 15.6% of KLAL eyes. The mean BCVA was 20/158 for KLAL eyes compared with 20/100 for lr-CLAL eyes at the last follow-up. A smaller proportion of lr-CLAL eyes (30.2% compared with 43.3%) developed an episode of acute rejection, and a higher proportion of these episodes resolved with treatment in the lr-CLAL group (79.0% compared with 53.6%). CONCLUSIONS: lr-CLAL demonstrates lower rejection rates, improved graft survival, and better BCVA compared with KLAL. Both careful preoperative donor selection and triple-agent systemic immunosuppression (including tapered systemic corticosteroids) are critical to optimizing the ocular surface stem cell transplantation outcomes.

6.
Transplantation ; 104(11): 2403-2414, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32000256

RESUMO

BACKGROUND: Reduction in donor-specific antibody (DSA) has been associated with improved renal allograft survival after antibody-mediated rejection (AMR). These observations have not been separately analyzed for early and late AMR and mixed acute rejection (MAR). The purpose of this study was to evaluate long-term responses to proteasome inhibitor-based therapy for 4 rejection phenotypes and to determine factors that predict allograft survival. METHODS: Retrospective cohort study evaluating renal transplant recipients with first AMR episodes treated with proteasome inhibitor-based therapy from January 2005 to July 2015. RESULTS: A total of 108 patients were included in the analysis. Immunodominant DSA reduction at 14 days differed significantly (early AMR 79.6%, early MAR 54.7%, late AMR 23.4%, late MAR 21.1%, P < 0.001). Death-censored graft survival (DCGS) differed at 3 years postrejection (early AMR 88.3% versus early MAR 77.8% versus late AMR 56.7% versus late MAR 54.9%, P = 0.02). Multivariate analysis revealed that immunodominant DSA reduction > 50% at 14 days was associated with improved DCGS (odds ratio, 0.12, 95% CI, 0.02-0.52, P = 0.01). CONCLUSIONS: In summary, significant differences exist across rejection phenotypes with respect to histological and DSA responses. The data suggest that DSA reduction may be associated with improved DCGS in both early and late AMR.

7.
Am J Transplant ; 20(2): 422-429, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31605562

RESUMO

Morbid obesity is a barrier to kidney transplant in patients with end-stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (SG) is an increasingly considered intervention, but the safety and long-term outcomes are uncertain. We reviewed prospectively collected data on patients with ESRD and chronic kidney disease (CKD) undergoing SG from 2011 to 2018. There were 198 patients with ESRD and 45 patients with CKD (stages 1-4) who met National Institutes of Health guidelines for bariatric surgery and underwent SG; 72% and 48% achieved a body mass index of ≤ 40 and ≤ 35 kg/m2 , respectively. The mean percentages of total weight loss and excess weight loss were 18.9 ± 10.8% and 38.2 ± 20.3%, respectively. SG reduced hypertension (85.8% vs 52.1%), decreased antihypertensive medication use (1.6 vs 1.0) (P < .01 each), and reduced incidence of diabetes (59.6% vs 32.5%, P < .01). Of the 71 patients with ESRD who achieved a body mass index of ≤ 40 kg/m2 , 45 were waitlisted and received a kidney transplant, whereas 10 remain on the waitlist. Mortality rate after SG was 1.8 per 100 patient-years, compared with 7.3 for non-SG. Patients with stage 3a or 3b CKD exhibited improved glomerular filtration rate (43.5 vs 58.4 mL/min, P = .01). In conclusion, SG safely improves transplant candidacy while providing significant, sustainable effects on weight loss, reducing medical comorbidities, and possibly improving renal function in stage 3 patients.

8.
Clin Transplant ; 33(7): e13598, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31104346

RESUMO

Hepatitis C (HCV) disease transmission from the use of HCV antibody-positive and HCV nucleic acid test-negative (HCV Ab+/NAT-) kidneys have been anecdotally reported to be absent. We prospectively analyzed kidney transplant (KT) outcomes from HCV Ab+/NAT- donors to HCV naïve recipients under T-cell depleting early steroid withdrawal immunosuppression. Allografts from 40 HCV Ab+/NAT- donors were transplanted to 52 HCV Ab- recipients between July 2016 and February 2018. Thirty-three (82.5%) of donors met Public Health Service (PHS) increased risk criteria. De novo HCV infection was detected at 3 months post-KT in one recipient (1.9%). This was a case of transmission from a HCV Ab+ NAT+ donor with an initial false-negative NAT completed using sample collected on donor hospital admission (day 2). At the time of HCV diagnosis, a stored donor sample collected during procurement (day 4) was tested and resulted NAT-positive. Subsequently, sustained virologic response (SVR) was achieved with 12 weeks of glecaprevir/pibrentasvir. One death with functioning graft at 261 days post-KT was determined not related to HCV or donor factors. This experience provides evidence of a low transmission rate of HCV from HCV Ab+/ NAT- kidney donors, thereby arguing for increasing utilization.


Assuntos
Seleção do Doador , Rejeição de Enxerto/etiologia , Hepacivirus/imunologia , Anticorpos Anti-Hepatite C/sangue , Hepatite C/transmissão , Transplante de Rim/efeitos adversos , Ácidos Urônicos/metabolismo , Adulto , Feminino , Seguimentos , Rejeição de Enxerto/diagnóstico , Sobrevivência de Enxerto , Hepatite C/diagnóstico , Hepatite C/virologia , Anticorpos Anti-Hepatite C/imunologia , Humanos , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco , Doadores de Tecidos/provisão & distribução , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Transplantados , Carga Viral
9.
Cornea ; 38(1): 123-126, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30371567

RESUMO

PURPOSE: To report our surgical experience with ocular surface stem cell transplantation (OSST) for limbal stem cell deficiency (LSCD) in the setting of keratitis-ichthyosis-deafness (KID) syndrome. METHODS: Retrospective interventional case series. RESULTS: We present 5 eyes of 3 patients with KID syndrome that developed LSCD and underwent OSST. Mean follow-up after OSST was 8.3 ± 4.3 years (range 3.4-11.4 years). Two eyes underwent living-related conjunctival limbal allograft (lr-CLAL), and 3 eyes were treated with keratolimbal allograft (KLAL). Four of the 5 eyes underwent subsequent keratoplasty. Both lr-CLAL eyes maintained a stable ocular surface at final follow-up. Conversely, all KLAL eyes developed a failed surface requiring repeat KLAL surgery. Because of multiple failed KLALs, 1 eye underwent placement of a keratoprosthesis. CONCLUSIONS: KID syndrome is a rare cause of LSCD. Although OSST can stabilize the surface, long-term treatment of KID syndrome can be challenging. An lr-CLAL may offer further benefit over a KLAL in these eyes because it is HLA- and ABO-matched tissue; it also helps to treat keratoconjunctivitis sicca, often a prominent feature of KID syndrome.


Assuntos
Túnica Conjuntiva/transplante , Ceratite/cirurgia , Transplante de Células-Tronco/métodos , Acuidade Visual , Adulto , Seguimentos , Humanos , Ceratite/diagnóstico , Masculino , Estudos Retrospectivos , Fatores de Tempo , Transplante Homólogo
10.
Cornea ; 37(11): 1395-1399, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30004958

RESUMO

PURPOSE: To describe the rate, clinical/microbiological characteristics, and outcomes of infectious keratitis in eyes with limbal stem cell deficiency after ocular surface stem cell transplantation (OSST). METHODS: In this retrospective chart review of 278 eyes that underwent OSST between January 2006 and December 2016, eyes treated for previous infectious keratitis (bacterial, fungal, or viral) were included. Demographics, risk factors, course, microbiological characteristics, and outcomes were assessed. RESULTS: A total of 52 eyes (18.7%) of 48 patients (28 men and 20 women) developed 75 episodes (culture-proven or presumed) of infectious keratitis (range 1-4 episodes) with mean follow-up of 5.3 ± 3.6 years after OSST. The most common limbal stem cell deficiency etiologies included chemical/thermal (27 episodes), Stevens-Johnson syndrome (19 episodes), aniridia (8 episodes), and mucous membrane pemphigoid (8 episodes). There were 44 (58.7%) bacterial keratitis episodes, 24 (32%) fungal keratitis episodes, and 7 (9.3%) HSV keratitis episodes. Gram-positive bacteria (79%) and Candida species (73%) were the most common bacterial and fungal pathogens. Before infection, 33% had an epithelial defect, 69% had a bandage contact lens, 91% were on systemic immunosuppression, and 25% recently had undergone ocular surgery (<3 months). Although 75% resolved with antimicrobial treatment, 25% required a therapeutic keratoplasty (TPK; 2 cases needed multiple TPK). CONCLUSIONS: Despite successful OSST surgery, infectious keratitis is relatively common, and aggressive medical/surgical therapy is warranted. Prophylactic topical antibiotics and a cicatrizing conjunctivitis diagnosis may account for the high proportion of fungal keratitis in this population.


Assuntos
Transplante de Córnea/efeitos adversos , Infecções Oculares/microbiologia , Ceratite/microbiologia , Limbo da Córnea/citologia , Complicações Pós-Operatórias/microbiologia , Transplante de Células-Tronco/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
11.
Cornea ; 37(9): 1192-1197, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29912041

RESUMO

PURPOSE: To describe our process for preoperative screening and donor selection for ocular surface stem cell transplantation (OSST). METHODS: A 7-year retrospective chart review was performed on limbal stem cell deficiency patients. The inclusion criterion was all patients who underwent an OSST procedure. The exclusion criterion was eyes with unilateral disease in which an autograft was performed. Data for human leukocyte antigen (HLA) typing, virtual crossmatching, donor-specific antibody, and panel reactive antibody level were obtained. RESULTS: Of the included 142 eyes (104 patients), 19 patients had no recorded living donor availability data, and HLA typing was not performed on 16 patients. A total of 94 donors (mean 1.4 donors/patient, range 1-6) were tested for 67 recipients. For 2 patients with graft-versus-host disease, no further HLA typing was needed, as the donors were known HLA-identical donors. For 47 patients, only 1 donor was tested, whereas multiple donors underwent HLA typing for 20 patients. There were 73 ABO (blood group)-compatible matches for the 61 tested recipients, and only 1 recipient did not have any ABO-compatible donor. For the virtual crossmatch, there were 5 patients who did not have a compatible donor (positive virtual crossmatch). The best available donor match was a sibling for 41 recipients (65%), a parent for 19 recipients (30%), and an offspring for 3 recipients (5%). CONCLUSIONS: Our protocol for OSST preoperative screening and donor selection minimizes the antigenic burden for transplanted tissue by selecting the best available donor match.


Assuntos
Seleção do Doador/métodos , Limbo da Córnea/citologia , Doadores Vivos , Transplante de Células-Tronco , Sistema ABO de Grupos Sanguíneos , Adulto , Tipagem e Reações Cruzadas Sanguíneas , Protocolos Clínicos , Doenças da Córnea/cirurgia , Feminino , Sobrevivência de Enxerto , Teste de Histocompatibilidade , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
13.
Ocul Surf ; 16(3): 294-300, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29572164

RESUMO

PURPOSE: To report the clinical features, management, and outcomes of patients with ocular surface damage secondary to Roman candle explosion accidents. METHODS: Retrospective, noncomparative, interventional case series of 11 patients with Roman candle explosion-related ocular surface injuries referred to the Cincinnati Eye Institute between 2007 and 2016. RESULTS: Eleven patients (10 male, 1 female, mean age 22.4 years) sustained unilateral ocular surface injuries with presenting visual acuity ranging from count fingers to light perception. All patients had severe limbal stem cell deficiency with total ocular surface failure. Eight eyes received a conjunctival-limbal autograft (CLAU) with a keratolimbal allograft (KLAL), 1 eye received a living related-conjunctival limbal allograft (lr-CLAL) with a KLAL, and 2 eyes received a CLAU with lr-CLAL. Nine eyes underwent subsequent penetrating keratoplasty, and 7 eyes had reconstructive eyelid surgery. Nine eyes demonstrated improved visual acuity at last follow-up; seven eyes demonstrated a stable ocular surface at last follow-up. Nonadherence was noted in 7 patients, either with poor adherence with post-operative treatment or poor follow-up; this portended a worse visual result. CONCLUSIONS: Roman candle-related accidents can lead to severe ocular surface injury. Despite total ocular surface failure, these eyes can achieve good postoperative visual results following limbal stem cell transplantation and subsequent keratoplasty with appropriate compliance.


Assuntos
Queimaduras Químicas , Explosões , Traumatismos Oculares , Adolescente , Adulto , Queimaduras Químicas/etiologia , Queimaduras Químicas/cirurgia , Criança , Túnica Conjuntiva/transplante , Traumatismos Oculares/etiologia , Traumatismos Oculares/cirurgia , Pálpebras/lesões , Pálpebras/cirurgia , Feminino , Humanos , Ceratoplastia Penetrante , Limbo da Córnea/citologia , Masculino , Estudos Retrospectivos , Transplante de Células-Tronco/métodos , Células-Tronco/patologia , Acuidade Visual , Adulto Jovem
14.
Transpl Infect Dis ; 20(1)2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29143415

RESUMO

BK polyomavirus mostly manifests as polyomavirus-associated nephropathy (PyVAN) in kidney transplant patients and polyoma virus-associated hemorrhagic cystitis (PyVHC) in bone marrow transplant patients. PyVHC in kidney transplant patients is only reported in four cases in the literature. Our patient had severe hemorrhagic cystitis without renal involvement. We postulate that our patient's exposure to ifosfamide and radiation 8 years prior transplantation might predispose him to this disease.


Assuntos
Vírus BK/isolamento & purificação , Cistite/virologia , Hemorragia/virologia , Infecções por Polyomavirus/virologia , Infecções Tumorais por Vírus/virologia , Adolescente , Adulto , Idoso , Antineoplásicos Alquilantes/uso terapêutico , Hemorragia/tratamento farmacológico , Hemorragia/etiologia , Humanos , Ifosfamida/uso terapêutico , Transplante de Rim , Masculino , Infecções por Polyomavirus/tratamento farmacológico , Infecções por Polyomavirus/etiologia , Transplante Homólogo , Infecções Tumorais por Vírus/tratamento farmacológico , Infecções Tumorais por Vírus/epidemiologia
15.
Clin Transplant ; 32(1)2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29140548

RESUMO

The endeavor to study desensitization in kidney transplantation has not been matched by an effort to investigate strategies to prevent sensitization. In this study (NCT02437422), we investigated the safety, impact on sensitization, and pharmacokinetics of SANGUINATE (SG), a hemoglobin-based oxygen carrier, as a potential alternative to packed red blood cells (PRBC) in transplant candidates with end-stage renal disease (ESRD). Ten ESRD subjects meeting inclusion/exclusion (I/E) criteria were planned to receive three weekly infusions of SG (320 mg/kg). The study was stopped after five subjects were enrolled, and their data were analyzed after completing a follow-up period of 90 days. Two subjects had elevated troponin I levels in setting of SG infusion, one of which was interpreted as a non-ST elevation myocardial infarction. All other adverse events were transient. SG pharmacokinetic analysis showed mean (SD) Cmax , Tmax , AUC, and half-life of 4.39 (0.69) mg/mL, 2.42 (0.91) hours, 171.86 (52.35) mg h/mL, and 40.60 (11.96) hours, respectively. None of the subjects developed new anti-HLA antibodies following SG infusion and throughout the study period. In conclusion, SG is a potential alternative to PRBCs in ESRD patients considered for kidney transplantation as it was not associated with humoral sensitization. Larger studies in highly sensitized patients are required to further evaluate for potential safety signals.


Assuntos
Substitutos Sanguíneos/uso terapêutico , Carboxihemoglobina/uso terapêutico , Antígenos HLA/imunologia , Falência Renal Crônica/tratamento farmacológico , Falência Renal Crônica/imunologia , Transplante de Rim/métodos , Adolescente , Adulto , Idoso , Animais , Bovinos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis/química , Prognóstico , Estudos Prospectivos , Adulto Jovem
16.
Cornea ; 36(12): 1570-1575, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29099734

RESUMO

PURPOSE: To describe the technique and present 2 cases of a combined conjunctival limbal autograft (CLAU) and living-related conjunctival limbal allograft (lr-CLAL) procedure for treatment of severe unilateral ocular surface failure. METHODS: Interventional case series of 2 eyes of 2 patients sustaining severe thermal/chemical injuries from firework explosions. They both underwent the combined CLAU/lr-CLAL procedure followed by penetrating keratoplasty. Systemic immunosuppression consisted of oral tacrolimus and mycophenolate mofetil. RESULTS: Preoperative vision was counting fingers for both patients, whereas visual acuity at last follow-up ranged between 20/40 and 20/50. Both patients maintained a stable surface at last follow-up without any episodes of rejection. Patients tolerated systemic immunosuppression well without any persistent adverse reactions. CONCLUSIONS: Certain etiologies of limbal stem cell deficiency also lead to significant conjunctival (and goblet cell) deficiency. Combined CLAU and lr-CLAL procedures maximize the amount of healthy limbal stem cells with conjunctiva while also minimizing the antigenic burden as all transplanted tissue potentially can be a complete (or near-complete), compatible HLA and crossmatch.


Assuntos
Queimaduras Químicas/terapia , Túnica Conjuntiva/citologia , Doenças da Córnea/terapia , Células Epiteliais/transplante , Queimaduras Oculares/induzido quimicamente , Limbo da Córnea/citologia , Doadores Vivos , Transplante de Células-Tronco , Aloenxertos , Autoenxertos , Queimaduras Químicas/fisiopatologia , Criança , Doenças da Córnea/fisiopatologia , Queimaduras Oculares/fisiopatologia , Feminino , Humanos , Masculino , Acuidade Visual/fisiologia , Adulto Jovem
17.
Am J Ophthalmol ; 184: 97-107, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29032107

RESUMO

PURPOSE: To investigate the long-term outcomes of ocular surface stem cell allograft transplantation (OSST) in patients with total limbal stem cell deficiency (LSCD) owing to various etiologies with a follow-up ≥ 5 years. DESIGN: Retrospective interventional cohort. METHODS: Setting: Single tertiary referral hospital. STUDY POPULATION: Patients who had (1) presence of total LSCD, (2) surgical treatment with at least 1 allograft OSST procedure, and (3) minimum follow-up ≥ 5 years after OSST. INTERVENTION: All patients underwent allograft OSST from March 1998 to June 2009. All patients received systemic immunosuppression. MAIN OUTCOME MEASURES: Ocular surface stability, best-corrected visual acuity (BCVA). RESULTS: A total of 165 eyes of 110 patients fulfilled the inclusion criteria with a mean follow-up period of 109.22 ± 35.7 months or approximately 9.1 years (range 5.2-17.7 years). Ocular surface stability was achieved in 72.7% (120/165) of eyes at last follow-up, while 15.2% (25/165) maintained an improved ocular surface and 12.1% (20/165) developed total surface failure. Additional OSST surgery was necessary in 30.9% (51/165 eyes) to maintain a stable ocular surface. There was ≥ 2 lines BCVA improvement in 62.1%, no change in 7.7%, and a worsened BCVA in 18.6% at last follow-up. CONCLUSIONS: With proper immunosuppression and repeat procedure in case of failure, allograft OSST can provide true long-term ocular surface stability and successful visual outcomes.


Assuntos
Doenças da Córnea/cirurgia , Epitélio Anterior/transplante , Limbo da Córnea/citologia , Transplante de Células-Tronco/métodos , Acuidade Visual , Adulto , Idoso , Aloenxertos , Doenças da Córnea/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
18.
Adv Chronic Kidney Dis ; 24(4): 228-232, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28778362

RESUMO

Acute kidney injury (AKI) is common in kidney transplant recipients. In addition to the usual causes of AKI in native kidneys, certain features and risk factors are unique to kidney allografts. In this article, we will present an overview of the common transplant-specific AKI etiologies that include increased susceptibility to hemodynamic-mediated AKI, acute rejection, medication-induced AKI, recurrence of native kidney disease, infections, urinary tract obstruction, vascular thrombosis and post-transplant lymphoproliferative disorder. AKI is independently associated with allograft loss and patient mortality. It is, therefore, prudent for transplant centers to address it as a major quality measure.


Assuntos
Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Rejeição de Enxerto/diagnóstico , Transplante de Rim/efeitos adversos , Infecções por Polyomavirus/diagnóstico , Infecções Tumorais por Vírus/diagnóstico , Obstrução Ureteral/diagnóstico , Vírus BK , Inibidores de Calcineurina/efeitos adversos , Diagnóstico Diferencial , Rejeição de Enxerto/complicações , Nível de Saúde , Humanos , Nefropatias/complicações , Nefropatias/cirurgia , Infecções por Polyomavirus/complicações , Recidiva , Fatores de Risco , Trombose/complicações , Resultado do Tratamento , Infecções Tumorais por Vírus/complicações , Obstrução Ureteral/complicações , Infecções Urinárias/complicações
19.
Cornea ; 36(8): 1006-1008, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28614157

RESUMO

PURPOSE: To report a case of probable donor-derived cytomegalovirus (CMV) infection after keratolimbal allograft (KLAL) transplantation. METHODS: Observational case report. RESULTS: A 41-year-old man with a history of aniridic keratopathy and limbal stem cell deficiency underwent KLAL in his right eye. Preoperatively, he was negative for CMV IgG and IgM. Postoperatively, he was maintained on tacrolimus and mycophenolate mofetil for systemic immunosuppression; he was also on prophylactic valganciclovir (for CMV) and trimethoprim/sulfamethoxazole (for pneumocystis pneumonia) for 1 month. Approximately 5 weeks postoperatively, he developed a nonproductive cough, rhinorrhea, and dyspnea. His condition did not improve with oral azithromycin or levofloxacin. He developed worsening symptoms over the next 2 weeks despite therapy. The serum CMV polymerase chain reaction was positive, and he was readministered valganciclovir with subsequent resolution of symptoms. CONCLUSIONS: We present the first case of CMV disease in a seronegative patient who received a presumed CMV-seropositive donor KLAL. Similar to solid organ transplantation, prophylactic and therapeutic management of CMV infection is necessary in the setting of systemic immunosuppression.


Assuntos
Doenças da Córnea/cirurgia , Infecções por Citomegalovirus/etiologia , Infecções Oculares Virais/etiologia , Transplante de Células-Tronco/efeitos adversos , Doadores de Tecidos , Adulto , Aloenxertos , Antivirais/uso terapêutico , Infecções por Citomegalovirus/diagnóstico , Infecções por Citomegalovirus/tratamento farmacológico , Quimioterapia Combinada , Infecções Oculares Virais/diagnóstico , Infecções Oculares Virais/tratamento farmacológico , Ganciclovir/análogos & derivados , Ganciclovir/uso terapêutico , Humanos , Limbo da Córnea/patologia , Masculino , Ácido Micofenólico/uso terapêutico , Tacrolimo/uso terapêutico , Valganciclovir
20.
Transplantation ; 99(10): 2167-73, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25856409

RESUMO

BACKGROUND: Classification of acute rejection (AR) based on etiology and timing may provide a means for enhancing therapeutic results and allograft survival. This study evaluated graft and patient survival after the first AR episodes among kidney transplant recipients with an early or late antibody-mediated rejection (AMR), acute cellular rejection (ACR) or mixed AR (MAR). METHODS: A prospective institutional review board-approved database was queried to identify biopsy-proven first AR episodes occurring from January 2005 to October 2012. The ACR was defined by Banff criteria; borderline AR was excluded. The AMR was defined as 3 of 4 criteria: renal dysfunction, donor specific antibody, C4d positivity on biopsy, and histological changes. The MAR met criteria for both ACR and AMR. Early AR occurred within six months post-transplant. AR episodes were then assigned to 1 of the 6 categories--early AMR, early ACR, early MAR, late AMR, late ACR, and late MAR. RESULTS: One hundred eighty-two kidney transplant recipients identified with a first AR episode. Mean follow-up was 773 days (± 715 days). No difference was observed in patient survival. Death-censored graft survival was 84%. Death-censored graft loss was higher with late versus early AMR (P = 0.01) and late versus early ACR (P = 0.03), but not late versus early MAR (P = 0.3). CONCLUSIONS: The AR type demonstrated a hierarchy for graft survival with ACR better than MAR better than AMR, which persisted for both early and late AR. Improvement in long-term results of AR may require development of specific treatment for individual AR types.


Assuntos
Sobrevivência de Enxerto , Transplante de Rim , Insuficiência Renal/mortalidade , Insuficiência Renal/cirurgia , Adulto , Biópsia , Complemento C4b/química , Bases de Dados Factuais , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto , Humanos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/química , Fenótipo , Estudos Prospectivos , Resultado do Tratamento
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