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1.
Clin Transplant ; 33(10): e13696, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31421057

RESUMO

We examined a novel linkage of national US donor registry data with records from a pharmacy claims warehouse (2007-2016) to examine associations (adjusted hazard ratio, LCL aHRUCL ) of post-donation fills of antidiabetic medications (ADM, insulin or non-insulin agents) with body mass index (BMI) at donation and other demographic and clinical factors. In 28 515 living kidney donors (LKDs), incidence of ADM use at 9 years rose in a graded manner with higher baseline BMI: underweight, 0.9%; normal weight, 2.1%; overweight, 3.5%; obese, 8.5%. Obesity was associated with higher risk of ADM use compared with normal BMI (aHR, 3.36 4.596.27 ). Metformin was the most commonly used ADM and was filled more often by obese than by normal weight donors (9-year incidence, 6.87% vs 1.85%, aHR, 3.55 5.007.04 ). Insulin use was uncommon and did not differ significantly by BMI. Among a subgroup with BMI data at the 1-year post-donation anniversary (n = 19 528), compared with stable BMI, BMI increase >0.5 kg/m2 by year 1 was associated with increased risk of subsequent ADM use (aHR, 1.03 1.482.14, P = .04). While this study did not assess the impact of donation on the development of obesity, these data support that among LKD, obesity is a strong correlate of ADM use.

3.
Infect Dis Clin North Am ; 32(3): 599-613, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30146025

RESUMO

BK virus (BKV) can cause graft dysfunction or failure in kidney transplant recipients and hemorrhagic cystitis in allogeneic hematopoietic stem cell transplant patients. BKV-associated nephropathy (BKVAN) emerged as a common complication in the late 1990s, probably due to the introduction of potent immunosuppressive agents. BKVAN occurred in up to 5% of kidney transplant recipients, with graft failure in up to 70%. Since universal implementation of effective screening and treatment strategies, BKV is no longer a common cause of graft failure; reported graft loss is only 0% to 5%. This article briefly describes BK virology, epidemiology, diagnosis, and management.


Assuntos
Vírus BK , Transplante de Rim/efeitos adversos , Transplante de Pâncreas/efeitos adversos , Infecções por Polyomavirus/complicações , Infecções Tumorais por Vírus/complicações , Antivirais/uso terapêutico , Humanos , Infecções por Polyomavirus/tratamento farmacológico , Infecções Tumorais por Vírus/tratamento farmacológico
4.
Clin Transplant ; 32(9): e13381, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30098053

RESUMO

Black kidney transplant recipients have more acute rejection (AR) and inferior graft survival. We sought to determine whether early steroid withdrawal (ESW) had an impact on AR and death-censored graft loss (DCGL) in blacks. From 2006 to 2012, AR and graft survival were analyzed in 483 kidney recipients (208 black and 275 non-black). Rates of ESW were similar between blacks (65%) and non-blacks (67%). AR was defined as early (≤3 months) or late (>3 months). The impact of black race, early AR, and late AR on death-censored graft failure was analyzed using univariate and multivariate Cox models. Blacks had greater dialysis vintage, more deceased donor transplants, and less HLA matching, yet rates of early AR were comparable between blacks and non-blacks. However, black race was a risk factor for late AR (HR: 3.48 (95% CI: 1.87-6.47)) Blacks had a greater rate of DCGL, partially driven by late AR (HR with late AR: 5.6; 95% CI: 3.3-9.3). ESW had no significant interaction with black race for risk of early AR, late AR, or DCGL. Independent of ESW, black kidney recipients had a higher rate of late AR after kidney transplantation. Late AR was highly predictive of DCGL and contributed to inferior graft survival in blacks.


Assuntos
Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto/efeitos dos fármacos , Disparidades em Assistência à Saúde , Imunossupressores/administração & dosagem , Transplante de Rim/efeitos adversos , Esteroides/administração & dosagem , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/diagnóstico , Humanos , Falência Renal Crônica/cirurgia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
6.
Exp Clin Transplant ; 15(6): 602-608, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28621634

RESUMO

OBJECTIVES: Transplant centers often recommend, but not necessarily require, screening colonoscopies for people over 50 years of age in accordance with the US Preventative Services Task Force guidelines for the general population. We sought to identify risk factors affecting colonoscopy results in renal failure patients undergoing kidney transplant evaluation. MATERIALS AND METHODS: We retrospectively examined patients undergoing kidney transplant evaluation from 2009 to 2012 (n = 469 patients). Comparisons were made between colonoscopy reports categorized as normal (no finding or hyperplastic polyp) or abnormal (adenomatous polyp or carcinoma). RESULTS: Of 469 patients who met the study criteria, 303 (64.6%) had normal colonoscopies and 166 (35.4%) had abnormal colonoscopies. Logistic regression analysis showed that male sex (odds ratio = 2.09; 95% confidence interval, 1.37-3.20; P = .001) and increasing age (odds ratio = 1.04; 95% confidence interval, 1.01-1.08; P = .019) were more likely to correspond to abnormal findings. Those with dialysis vintage (length of time on dialysis) up to 3 years (odds ratio = 2.10; 95% confidence interval, 1.09-4.06; P = .027) and hypertension as the cause of renal failure (odds ratio = 1.79; 95% confidence interval, 1.05-2.87; P = .002) had more abnormal findings. No differences in length of evaluation, rate of being listed for transplant, and rate of transplant were shown. CONCLUSIONS: The overall rate of adenomatous findings on colonoscopy was higher among patients with pretransplant end-stage renal disease than in the general population, as shown in other studies. Age, sex, dialysis vintage up to 3 years, and hypertensive renal failure were associated with adenomatous polyps of the colon in this study population. Because adenomatous polyp rates are high in patients with chronic kidney disease who are undergoing transplant evaluation and colonoscopic findings do not appear to delay transplant evaluations or listing rates, screening colonoscopies should be encouraged.


Assuntos
Pólipos Adenomatosos/diagnóstico , Carcinoma/diagnóstico , Neoplasias do Colo/diagnóstico , Pólipos do Colo/diagnóstico , Colonoscopia , Falência Renal Crônica/diagnóstico , Transplante de Rim , Pólipos Adenomatosos/complicações , Idoso , Carcinoma/complicações , Distribuição de Qui-Quadrado , Neoplasias do Colo/complicações , Pólipos do Colo/complicações , Feminino , Humanos , Hipertensão/complicações , Falência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Listas de Espera
7.
Am J Cardiol ; 118(1): 132-7, 2016 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-27189814

RESUMO

Concerns exist regarding orthotropic heart transplantation in hepatitis C virus (HCV) seropositive recipients. Thus, a national registry was accessed to evaluate early and late outcome in HCV seropositive recipients undergoing heart transplant. Retrospective analysis of the United Network for Organ Sharing registry (1991 to 2014) was performed to evaluate recipient profile and clinical outcome of patients with HCV seropositive (HCV +ve) and seronegative (HCV -ve). Adjusted results of early mortality and late survival were compared between cohorts. From 23,507 patients (mean age 52 years; 75% men), 481 (2%) were HCV +ve (mean age 52 years; 77% men). Annual proportion of HCV +ve recipients was comparable over the study period (range 1.3% to 2.7%; p = 0.2). The HCV +ve cohort had more African-American (22% vs 17%; p = 0.01), previous left ventricular assist device utilization (21% vs 14%; p <0.01) and more hepatitis B core Ag+ve recipients (17% vs 5%; p <0.01). However, both cohorts were comparable in terms of extracorporeal membrane oxygenator usage (p = 0.7), inotropic support (p = 0.2), intraaortic balloon pump (p = 0.7) support, serum creatinine (p = 0.7), and serum bilirubin (p = 0.7). Proportion of status 1A patients was similar (24% HCV + vs 21% HCV -); however, wait time for HCV +ve recipients were longer (mean 23 vs 19 days; p <0.01). Among donor variables, age (p = 0.8), hepatitis B status (p = 0.4), and Center for Diseases Control high-risk status (p = 0.9) were comparable in both cohorts. At a median follow-up of 4 years, 67% patients were alive, 28% died, and 1.1% were retransplanted (3.4% missing). Overall survival was worse in the HCV+ cohort (64.3% vs 72.9% and 43.2% vs 55% at 5 and 10 years; p <0.01), respectively. Late renal (odds ratio [OR] 1.2 [1 to 1.6]; p = 0.02) and liver dysfunction (odds ratio 4.5 [1.2 to 15.7]; p = 0.01) occurs more frequently in HCV +ve recipients. On adjusted analysis, HCV seropositivity is associated with poorer survival (hazard ratio for mortality 1.4 [1.1 to 1.6]; p <0.001). In conclusion, a small proportion of patients receiving a heart transplant in the United States have hepatitis C. Despite comparable preoperative hepatic function, hepatitis C seropositive recipients demonstrate poorer long-term survival.


Assuntos
Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Hepatite C/complicações , Adulto , Feminino , Sobrevivência de Enxerto , Insuficiência Cardíaca/virologia , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
8.
FP Essent ; 444: 11-7, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27163760

RESUMO

Acute kidney injury (AKI) refers to any acute decrease in glomerular filtration rate, regardless of etiology. Staging of AKI has been recommended to stratify AKI patients according to severity of the condition, based on serum creatinine level and urine output. Classification of AKI into prerenal, intrinsic renal, and postrenal etiologies is helpful in differential diagnosis and management. AKI in hospitalized patients typically occurs due to decreased renal perfusion. Drug-induced, contrast-associated, postoperative, and sepsis-associated AKI also can occur. Clinical assessment of a patient with AKI involves a medical record review, thorough history and physical examination, urinary and blood tests, renal imaging, and, in some instances, renal biopsy. Contrast-induced nephropathy is a common iatrogenic etiology of AKI associated with administration of intravenous iodinated contrast media. Measures to prevent AKI should be taken before administration of intravenous iodinated contrast. AKI can result in many short- and long-term complications, including chronic kidney disease and end-stage renal disease. Appropriate treatment of AKI patients involves management of the underlying etiology, when possible, and use of nondialytic and dialytic therapies.


Assuntos
Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Idoso , Antibacterianos/uso terapêutico , Baixo Débito Cardíaco/complicações , Meios de Contraste/efeitos adversos , Creatinina/sangue , Creatinina/urina , Desidratação/complicações , Desidratação/diagnóstico , Desidratação/terapia , Diuréticos/uso terapêutico , Hidratação , Taxa de Filtração Glomerular , Glomerulonefrite/complicações , Humanos , Isquemia/complicações , Masculino , Nefrite Intersticial/complicações , Diálise Renal , Obstrução Ureteral/complicações , Obstrução Uretral/complicações , Cateterismo Urinário , Infecções Urinárias/complicações , Infecções Urinárias/diagnóstico , Infecções Urinárias/tratamento farmacológico
10.
Clin Transplant ; 30(4): 445-51, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26855387

RESUMO

UNLABELLED: Transplant centers typically require screening mammography (MMG) for women ≥40 during evaluation. American Cancer Society recommends starting annual MMG at 40, while USPSTF recommends biennial MMG at 50. We sought to determine the effect of age and other breast malignancy risk factors on screening MMG in the pre-transplant renal failure population undergoing transplant evaluation. METHODS: We retrospectively examined women ≥40 undergoing kidney transplant evaluation from 2006 to 2012 (n = 541). RESULTS: Patients aged 40.0-49.9 and ≥50 had similar rates of breast biopsy and breast malignancy. African Americans underwent a higher rate of biopsies (OR 2.391, 95%CI 1.111-5.019, p = 0.026), with a lower rate of biopsy in those already on dialysis at presentation (OR 0.434, 95%CI 0.212-0.888, p = 0.022). Higher breast density (>50% fibroglandular tissue) increased both rate of biopsy (OR 2.876, 95%CI 1.377-6.010, p = 0.005) and malignancy (OR 5.061, 95%CI 1.012-25.315, p = 0.048). CONCLUSIONS: As we found no independent differences in biopsy or malignancy between age groups, it is reasonable for transplant centers to use the same evaluation MMG screening policy for all women ≥40. However, as malignancy risk increased with higher breast density, a lower threshold for additional workup may be warranted in patients with dense breasts or an indeterminate lesion on MMG.


Assuntos
Neoplasias da Mama/diagnóstico , Falência Renal Crônica/patologia , Falência Renal Crônica/cirurgia , Transplante de Rim , Mamografia/estatística & dados numéricos , Adulto , Idoso , Biópsia , Neoplasias da Mama/complicações , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Testes de Função Renal , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos
11.
Transplantation ; 97(6): 648-53, 2014 Mar 27.
Artigo em Inglês | MEDLINE | ID: mdl-24637864

RESUMO

BACKGROUND: Patients returning to dialysis therapy after renal transplant failure have high morbidity and retransplant rates. After observing frequent hospitalizations with fever after failure, it was hypothesized that maintaining immunosuppression for the failed allograft increases the risk of infection, while weaning immunosuppression can lead to symptomatic rejection mimicking infection. METHODS: One hundred eighty-six patients with failed kidney transplants were analyzed for rates of hospitalization with fever within 6 months of allograft failure. Patients were stratified by the presence of full immunosuppression versus minimal (low-dose prednisone) or no immunosuppression, before hospital admission. Subsequent rates of documented infection and nephrectomy, as well as patient survival, were ascertained. RESULTS: Hospitalization with fever within 6 months of allograft failure was common, occurring in 44% of patients overall. However, among febrile hospitalized patients who had been weaned off of immunosuppression before admission, only 38% had documented infection. In contrast, 88% of patients maintained on immunosuppression had documented infection (P<0.001). In both groups, dialysis catheter-related infections were the most common infection source. Allograft nephrectomy was performed in 81% of hospitalized patients with no infection, compared to 30% of patients with documented infection (P<0.001). Mortality risk was significantly higher in patients with concurrent pancreas transplants or who were hospitalized with documented infection. CONCLUSIONS: Maintenance immunosuppression after kidney allograft failure was associated with a greater incidence of infection, while weaning of immunosuppression commonly resulted in symptomatic rejection with fever mimicking infection on presentation. Management of the failed allograft should include planning to avoid both infection and sensitizing events.


Assuntos
Doenças Transmissíveis/etiologia , Febre/etiologia , Rejeição de Enxerto/etiologia , Imunossupressores/efeitos adversos , Transplante de Rim/efeitos adversos , Adulto , Doenças Transmissíveis/mortalidade , Doenças Transmissíveis/terapia , Esquema de Medicação , Feminino , Febre/mortalidade , Febre/terapia , Rejeição de Enxerto/mortalidade , Rejeição de Enxerto/terapia , Humanos , Imunossupressores/administração & dosagem , Estimativa de Kaplan-Meier , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Nefrectomia , Transplante de Pâncreas/efeitos adversos , Readmissão do Paciente , Diálise Renal , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Falha de Tratamento
14.
Semin Dial ; 24(3): 343-8, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21198847

RESUMO

Obtaining renal tissue is often critical in the diagnosis and management of patients with renal disease of unknown etiology. Bleeding diathesis, liver disease, and obesity are common contraindications for percutaneous renal biopsy. In high-risk patients, transjugular renal biopsy is believed to be a safe and effective procedure. This study reports the experience of an academic interventional nephrology program with performing transjugular renal biopsy. We performed a retrospective observational study of 23 patients with either acute or chronic kidney disease with contraindications for percutaneous renal biopsy. All transjugular renal biopsies were performed by interventional nephrologists at our university. We studied the efficacy and safety of transjugular renal biopsy in these patients. Twenty out of 23 (87%) of the procedures yielded adequate tissue for pathologic diagnosis. Three (13%) patients required blood transfusions, none required coil embolization or nephrectomy, and there were no deaths. Even though performing transjugular renal biopsy requires considerable technical expertise and must be performed in an interventional radiology suite, it can be safely and effectively performed by well-trained interventional nephrologists to achieve pathological diagnosis.


Assuntos
Biópsia por Agulha/métodos , Veias Jugulares , Rim/patologia , Radiografia Intervencionista/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Renal/diagnóstico por imagem , Estudos Retrospectivos
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