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1.
Clin Transplant ; : e13878, 2020 Apr 12.
Artigo em Inglês | MEDLINE | ID: mdl-32279361

RESUMO

As the medical community is increasingly offering transplantation to patients with increasing comorbidity burdens, the number of simultaneous heart-kidney (SHK) transplants is rising in the United States. How to determine eligibility for SHK transplant versus heart transplant alone is unknown. In this review, we situate this problem in the broader picture of organ shortage. We critically appraise available literature on outcomes in SHK versus heart transplant alone. We posit staged kidney-after-heart transplantation as a plausible alternative to SHK transplantation and review the pros and cons. Drawing lessons from the field of simultaneous liver-kidney transplant, we argue for an analogous policy for SHK transplant with standardized minimal eligibility criteria and a modified Safety Net provision. The new policy will serve as a starting point for comparing simultaneous versus staged approaches and refining the medical eligibility criteria for SHK.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32191296

RESUMO

The construct of frailty was first developed in gerontology to help identify older adults with increased vulnerability when confronted with a health stressor. This article is a review of studies in which frailty has been applied to pre- and post-kidney transplantation (KT) populations. Although KT is the optimal treatment for end-stage kidney disease (ESKD), KT candidates often must overcome numerous health challenges associated with ESKD before receiving KT. After KT, the impacts of surgery and immunosuppression represent additional health stressors that disproportionately impact individuals with frailty. Frailty metrics could improve the ability to identify KT candidates and recipients at risk for adverse health outcomes and those who could potentially benefit from interventions to improve their frail status. The Physical Frailty Phenotype (PFP) is the most commonly used frailty metric in ESKD research, and KT recipients who are frail at KT (~20% of recipients) are twice as likely to die as nonfrail recipients. In addition to the PFP, many other metrics are currently used to assess pre- and post-KT vulnerability in research and clinical practice, underscoring the need for a disease-specific frailty metric that can be used to monitor KT candidates and recipients. Although frailty is an independent risk factor for post-transplant adverse outcomes, it is not factored into the current transplant program risk-adjustment equations. Future studies are needed to explore pre- and post-KT interventions to improve or prevent frailty.

3.
Transplantation ; 104(2): 387-394, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31107820

RESUMO

BACKGROUND: Organ scarcity continues in solid organ transplantation, such that the availability of organs limits the number of people able to benefit from transplantation. Medical advancements in managing end-stage organ disease have led to an increasing demand for multiorgan transplant, wherein a patient with multiorgan disease receives >1 organ from the same donor. Current allocation schemes give priority to multiorgan recipients compared with single-organ transplant recipients, which raise ethical questions regarding equity and utility. METHODS: We use simultaneous liver and kidney (SLK) transplant, a type of multiorgan transplant, as a case study to examine the tension between equity and utility in multiorgan allocation. We adapt the health economics willingness-to-pay threshold to a solid organ transplant setting by coining a new metric: the willingness-to-transplant (WTT) threshold. RESULTS: We demonstrate how the WTT threshold can be used to evaluate different SLK allocation strategies by synthesizing utility and equity perspectives. CONCLUSIONS: We submit that this new framework enables us to distill the question of SLK allocation down to: what is the minimum amount of benefit we require from a deceased donor kidney to allocate it for a particular indication? Addressing the above question will prove helpful to devising a rational system of SLK allocation and is applicable to other transplant settings.

4.
Transplantation ; 104(2): 349-356, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31343576

RESUMO

BACKGROUND: Given the potential utility of frailty, a clinical phenotype of decreased physiologic reserve and resistance to stressors, to predict postkidney transplant (KT) outcomes, we sought to understand the perceptions and practices regarding frailty measurement in US KT programs. METHODS: Surveys were emailed to American Society of Transplantation Kidney/Pancreas Community of Practice members and 202 US transplant programs (November 2017 to April 2018). Program characteristics were gleaned from Scientific Registry of Transplant Recipients. RESULTS: The 133 responding programs (response rate = 66%) represented 77% of adult KTs and 79% of adult KT candidates in the United States. Respondents considered frailty to be a useful concept in evaluating candidacy (99%) and endorsed a need to develop a frailty measurement specific to KT (92%). Frailty measurement was more common during candidacy evaluation (69%) than during KT admission (28%). Of the 202 programs, 38% performed frailty assessments in all candidates while 23% performed assessments only for older candidates. There was heterogeneity in the frailty assessment method; 18 different tools were utilized to measure frailty. The most common tool was a timed walk test (19%); 67% reported performing >1 tool. Among programs that measure frailty, 53% reported being less likely to list frail patients for KT. CONCLUSIONS: Among US KT programs, frailty is recognized as a clinically relevant construct and is commonly measured at evaluation. However, there is considerable heterogeneity in the tools used to measure frailty. Efforts to identify optimal measurement of frailty using either an existing or a novel tool and subsequent standardization of its measurement and application across KT programs should be considered.

5.
Curr Transplant Rep ; 6(1): 16-25, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31131186

RESUMO

Purpose of Review: Research over the past few decades points to the importance of frailty, or the lack of physiologic reserve, in the natural history of chronic diseases and in modifying the impact of potential interventions. End-stage kidney disease (ESKD) and the intervention of kidney transplantation are no exception. We review the recent epidemiologic and cohort-based evidence on the association between frailty and kidney transplant outcomes and provide a framework of questions with which to approach future research endeavors and clinical practice. Recent Findings: Frailty in kidney transplant candidates can be measured in numerous ways, including descriptive phenotype, description scores, functional testing, and surrogate measures. Regardless of the metric, the presence of frailty is strongly associated with inferior pre- and posttransplant outcomes compared to the absence of frailty. However, some frail patients with ESKD can benefit from transplant over chronic dialysis. Evidence-based approaches for identifying frail ESKD patients who can benefit from transplant over dialysis, with acceptable posttransplant outcomes, are lacking. Interventional trials to improve frailty and physical function before transplant (prehabilitation) and after transplant (rehabilitation) are also lacking. Conclusion: Frailty is increasingly recognized as highly relevant to peritransplant outcomes, but more work is needed to: 1) tailor management to the unique needs of frail patients, both pre- and posttransplant; 2) define phenotypes of frail patients who are expected to benefit from transplant over dialysis; and 3) develop interventions to reverse frailty, both pre- and post-transplant.

6.
J Infect Dis ; 220(3): 370-376, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-30869132

RESUMO

BACKGROUND: BK virus (BKV) is a significant cause of nephropathy in kidney transplantation. The goal of this study was to characterize the course and source of BKV in kidney transplant recipients. METHODS: We prospectively collected pretransplant plasma and urine samples from living and deceased kidney donors and performed BKV polymerase chain reaction (PCR) and immunoglobulin G (IgG) testing on pretransplant and serially collected posttransplant samples in kidney transplant recipients. RESULTS: Among deceased donors, 8.1% (17/208) had detectable BKV DNA in urine prior to organ procurement. BK viruria was observed in 15.4% (6/39) of living donors and 8.5% (4/47) of deceased donors of recipients at our institution (P = .50). BKV VP1 sequencing revealed identical virus between donor-recipient pairs to suggest donor transmission of virus. Recipients of BK viruric donors were more likely to develop BK viruria (66.6% vs 7.8%; P < .001) and viremia (66.6% vs 8.9%; P < .001) with a shorter time to onset (log-rank test, P < .001). Though donor BKV IgG titers were higher in recipients who developed BK viremia, pretransplant donor, recipient, and combined donor/recipient serology status was not associated with BK viremia (P = .31, P = .75, and P = .51, respectively). CONCLUSIONS: Donor BK viruria is associated with early BK viruria and viremia in kidney transplant recipients. BKV PCR testing of donor urine may be useful in identifying recipients at risk for BKV complications.


Assuntos
Vírus BK/isolamento & purificação , Nefropatias/virologia , Transplante de Rim/efeitos adversos , Infecções por Polyomavirus/virologia , Infecções Tumorais por Vírus/virologia , Adulto , Feminino , Humanos , Imunoglobulina G/sangue , Rim/virologia , Nefropatias/sangue , Nefropatias/urina , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Infecções por Polyomavirus/sangue , Infecções por Polyomavirus/urina , Estudos Prospectivos , Transplantados , Infecções Tumorais por Vírus/sangue , Infecções Tumorais por Vírus/urina , Viremia/sangue , Viremia/urina , Viremia/virologia
7.
Am J Transplant ; 19(8): 2306-2317, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30664327

RESUMO

For many patients with end-stage kidney disease, transplantation improves survival and quality of life compared with dialysis. However, complications and side effects in kidney transplant recipients can limit their ability to participate in activities of daily living including work, study, and recreational activities. The aim of this study was to identify the characteristics, content, and psychometric properties of the outcome measures used to assess life participation in kidney transplant recipients. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018 for all studies that reported life participation in kidney transplant recipients. Two authors identified instruments measuring life participation and reviewed for characteristics. In total, 230 studies were included: 19 (8%) randomized trials, 17 (7%) nonrandomized trials, and 194 (85%) observational studies. Across these studies, we identified 29 different measures that were used to assess life participation. Twelve (41%) measures specifically assessed aspects of life participation (eg, disability assessment, daily activities of living), while 17 (59%) assessed other constructs (eg, quality of life) that included questions on life participation. Validation data to support the use of these measures in kidney transplant recipients were available for only 7 measures. A wide range of measures have been used to assess life participation in kidney transplant recipients, but validation data supporting the use of these measures in this population are sparse. A content relevant and validated measure to improve the consistency and accuracy of measuring life participation in research may inform strategies for transplant recipients to be better able to engage in their life activities.

8.
Transpl Infect Dis ; 21(1): e12998, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30203504

RESUMO

We present a case of cytomegalovirus (CMV) native kidney nephritis and prostatitis in a CMV D+/R- kidney transplant recipient who had completed six months of CMV prophylaxis four weeks prior to the diagnosis of genitourinary CMV disease. The patient had a history of benign prostatic hypertrophy and urinary retention that required self-catheterization to relieve high post-voiding residual volumes. At 7 months post-transplant, he was found to have a urinary tract infection, moderate hydronephrosis of the transplanted kidney, and severe hydroureteronephrosis of the native left kidney and ureter, and underwent native left nephrectomy and transurethral resection of the prostate. Histopathologic examination of kidney and prostate tissue revealed CMV inclusions consistent with invasive CMV disease. This case highlights that CMV may extend beyond the kidney allograft to involve other parts of the genitourinary tract, including the native kidneys and prostate. Furthermore, we highlight the tissue-specific risk factors that preceded CMV tissue invasion. In addition to concurrent diagnoses, health care providers should have a low threshold for considering late-onset CMV disease in high-risk solid organ transplant recipients presenting with signs and symptoms of genitourinary tract pathology.


Assuntos
Infecções por Citomegalovirus/diagnóstico , Citomegalovirus/isolamento & purificação , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Nefrite/diagnóstico , Prostatite/diagnóstico , Aloenxertos/virologia , Antibioticoprofilaxia/métodos , Antivirais/uso terapêutico , Biópsia , Infecções por Citomegalovirus/patologia , Infecções por Citomegalovirus/prevenção & controle , Infecções por Citomegalovirus/virologia , Humanos , Rim/patologia , Rim/virologia , Masculino , Pessoa de Meia-Idade , Nefrite/microbiologia , Nefrite/patologia , Próstata/patologia , Próstata/virologia , Prostatite/patologia , Prostatite/virologia , Transplantados , Resultado do Tratamento
9.
Clin Transplant ; 32(11): e13406, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30218580

RESUMO

Kidney transplant wait-list management is becoming increasingly complex. We introduced a novel wait-list management strategy at our center, the Transplant Readiness Assessment Clinic (TRAC), whereby patients whose Kidney Allocation Scores surpass a threshold are actively managed. From January 1, 2016 through June 30, 2017, we evaluated 195 patients through TRAC. Compared to pre-TRAC systems at our institution, TRAC resulted in a higher proportion of activation at 18 months (38% vs 22%-26%, P < 0.0001), despite being enriched in patients with long dialysis duration. TRAC also resulted in a higher proportion of wait-list removal (15% vs 8%-9%, P < 0.05) although combined wait-list removal and death on wait-list did not differ (18% vs 16%-17%). Median time to activation was 356 days from TRAC evaluation. Of the transplant barriers, need for cardiovascular studies was the most common (31%), followed by other medical issues (23%), poor functional status (13%), and psychosocial issues (10%). By concentrating center resources on patients most likely to be transplanted after activation and performing active patient management close to the time of transplant, TRAC has the potential to significantly enhance kidney transplant success in regions with long wait-times.


Assuntos
Alocação de Recursos para a Atenção à Saúde/normas , Falência Renal Crônica/cirurgia , Transplante de Rim/estatística & dados numéricos , Alocação de Recursos/normas , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Listas de Espera , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Diálise Renal , Fatores de Risco , Fatores de Tempo
10.
Clin Transplant ; 32(11): e13414, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30240515

RESUMO

Many heart transplant recipients experience declining kidney function following transplantation. We aimed to quantify change in kidney function in heart transplant recipients stratified by pre-transplant kidney function. A total of 230 adult heart transplant recipients between May 1, 2008, and December 31, 2014, were evaluated for up to 5 years post-transplant (median 1 year). Using 19 398 total estimated glomerular filtration rate (eGFR) assessments, we evaluated trends in eGFR in recipients with normal/near-normal (eGFR ≥45 mL/min/1.73 m2 ) vs impaired (eGFR <45 mL/min/1.73 m2 ) kidney function and the likelihood of reaching an eGFR of 20 mL/min/1.73 m2 after heart transplant. Baseline characteristics were similar. Immediately following heart transplant, the impaired pre-transplant kidney function group showed a mean eGFR gain of 9.5 mL/min/1.73 m2 (n = 193) vs a mean decline of 4.9 mL/min/1.73 m2 (n = 37) in the normal/near-normal group. Subsequent rates of eGFR decline were 2.2 mL/min/1.73 m2 /y vs 2.9 mL/min/1.73 m2 /y, respectively. The probability of reaching an eGFR of 20 mL/min/1.73 m2 or less at 1, 5, and 10 years following heart transplant was 1%, 4%, and 30% in the impaired group, and <1%, <1%, and 10% in the normal/near-normal group. Estimates of expected recovery in kidney function and its decline over time will help inform decision making about kidney care after heart transplantation.


Assuntos
Rejeição de Enxerto/etiologia , Transplante de Coração/efeitos adversos , Complicações Pós-Operatórias , Insuficiência Renal/etiologia , Feminino , Seguimentos , Taxa de Filtração Glomerular , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Humanos , Testes de Função Renal , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência Renal/patologia , Fatores de Risco , Fatores de Tempo
11.
Diseases ; 6(3)2018 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-29996536

RESUMO

In recent years, the opioid epidemic and new hepatitis C virus (HCV) treatments have changed the landscape of organ procurement and allocation. We studied national trends in solid organ transplantation (2000⁻2016), focusing on graft utilization from HCV seropositive deceased donors in the pre-2014 (2000⁻2013) versus current (2014⁻2016) eras with a retrospective analysis of the United Network for Organ Sharing database. During the study period, HCV seropositive donors increased from 181 to 661 donors/year. The rate of HCV seropositive donor transplants doubled from 2014 to 2016. Heart and lung transplantation data were too few to analyze. A higher number of HCV seropositive livers were transplanted into HCV seropositive recipients during the current era: 374 versus 124 liver transplants/year. Utilization rates for liver transplantation reached parity between HCV seropositive and non-HCV donors. While the number of HCV seropositive kidneys transplanted to HCV seropositive recipients increased from 165.4 to 334.7 kidneys/year from the pre-2014 era to the current era, utilization rates for kidneys remained lower in HCV seropositive than in non-HCV donors. In conclusion, relative underutilization of kidneys from HCV seropositive versus non-HCV donors has persisted, in contrast to trends in liver transplantation.

12.
Transplantation ; 102(5): e219-e228, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29554056

RESUMO

BACKGROUND: The proportion of patients with kidney failure at time of liver transplantation is at a historic high in the United States. The optimal timing of kidney transplantation with respect to the liver transplant is unknown. METHODS: We used a modified cost-effectiveness analysis to compare 4 strategies: the old system ("pre-OPTN"), the new Organ Procurement Transplant Network (OPTN) system since August 10, 2017 ("OPTN"), and 2 strategies which restrict simultaneous liver-kidney transplants ("safety net" and "stringent"). We measured "cost" by deployment of deceased donor kidneys (DDKs) to liver transplant recipients and effectiveness by life years (LYs) and quality-adjusted life years (QALYs) in liver transplant recipients. We validated our model against Scientific Registry for Transplant Recipients data. RESULTS: The OPTN, safety net and stringent strategies were on the efficiency frontier. By rank order, OPTN > safety net > stringent strategy in terms of LY, QALY, and DDK deployment. The pre-OPTN system was dominated, or outperformed, by all alternative strategies. The incremental LY per DDK between the strategies ranged from 1.30 to 1.85. The incremental QALY per DDK ranged from 1.11 to 2.03. CONCLUSIONS: These estimates quantify the "organ"-effectiveness of various kidney allocation strategies for liver transplant candidates. The OPTN system will likely deliver better liver transplant outcomes at the expense of more frequent deployment of DDKs to liver transplant recipients.


Assuntos
Custos de Cuidados de Saúde , Transplante de Rim/economia , Transplante de Fígado/economia , Obtenção de Tecidos e Órgãos/economia , Análise Custo-Benefício , Feminino , Humanos , Transplante de Rim/efeitos adversos , Transplante de Rim/métodos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento/economia , Obtenção de Tecidos e Órgãos/métodos , Resultado do Tratamento , Estados Unidos
13.
Transplantation ; 102(3): 454-460, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28976413

RESUMO

BACKGROUND: Hepatitis C virus (HCV) infection is common among kidney transplant (KTx) recipients. However, the impact of HCV infection on long-term graft and recipient survival after KTx from large-scale data remains to be determined. METHODS: We used the Organ Procurement and Transplantation Network database to identify all adults undergoing KTx in 2004 to 2006 in the United States. A propensity score was created to match each HCV-positive recipient with an HCV-negative control for unbiased comparisons. Survival analysis was conducted to evaluate recipient and death-censored graft survival. RESULTS: Out of 33 357 adult primary KTx recipients, 1470 (4.4%) were HCV-positive: 1364 HCV-positive and -negative pairs were selected by propensity score matching. Based on multivariable regression models, HCV is associated with a higher risk of death (hazard ratio [HR], 1.50; 95% confidence interval [95% CI], 1.28-1.75) and graft failure (HR, 1.26; 95% CI, 1.08-1.47). Infection was a more common cause of death in HCV-positive patients than in HCV-negative recipients (HR, 1.64; 95% CI, 1.12-2.42). The incidence of death due to liver failure was 0.23% per year among HCV-positive recipients, whereas no HCV-negative recipients died from liver failure. Graft failure due to recurrent disease was higher in HCV-positive than in HCV-negative recipients (HR, 2.00; 95% CI, 1.06-3.78). CONCLUSION: HCV infection is associated with decreased long-term recipient and graft survival. Future studies are needed to examine whether recently available, safe, and effective antiviral therapy improves the long-term clinical outcome in these patients.


Assuntos
Sobrevivência de Enxerto , Hepatite C/complicações , Transplante de Rim/mortalidade , Adulto , Idoso , Feminino , Hepatite C/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
Curr Transplant Rep ; 4(4): 320-326, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29201600

RESUMO

Purpose of Review: The risks following living kidney donation has been the subject of rigorous investigation in the past several decades. How to utilize the burgeoning new knowledge base to better the risk assessment, education, and health maintenance of donors is unclear. We review the physiologic and epidemiologic evidences on the post-donation state and submit a multiple-hit hypothesis to reconcile the finite elevation in risk of kidney disease after donation with the benign course of most kidney donors. Recent Findings: The risk of end-stage kidney disease is higher in kidney donors compared to similarly healthy non-kidney donors. Nonetheless, post-donation kidney disease is uncommon and arises mostly in the setting of other "hits"-either a "first hit" present at birth or a "second hit" acquired later in life. Summary: The transplant community's focus should be directed toward (1) personalized risk assessment to inform consent before donation and (2) preventing and treating development of "second hits" following kidney donation.

15.
Clin Transplant ; 31(8)2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28564126

RESUMO

Many patients become frail with diminished cardiorespiratory fitness while awaiting kidney transplantation. Frailty and poor fitness powerfully predict mortality, transplant graft survival, and healthcare utilization after kidney transplantation. Efforts to intervene with post-transplant physical therapy have been met with limited success, in large part due to high study dropout. We reviewed the literature on chronic kidney disease and exercise to propose a clinical framework for physical therapy interventions to improve fitness, scheduled for before the transplant. This framework may lead to better patient retention and compliance, and thus demonstrate better efficacy in mitigating the effects of frailty and poor fitness after kidney transplantation.


Assuntos
Falência Renal Crônica/reabilitação , Transplante de Rim , Modalidades de Fisioterapia , Cuidados Pré-Operatórios/métodos , Teste de Esforço , Fragilidade , Humanos , Falência Renal Crônica/fisiopatologia , Falência Renal Crônica/cirurgia , Aptidão Física
16.
Transplantation ; 101(5): 1111-1119, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28437790

RESUMO

BACKGROUND: Simultaneous liver-kidney (SLK) transplantation plays an important role in treating kidney failure in patients with end-stage liver disease. It used 5% of deceased donor kidney transplanted in 2015. We evaluated the utility, defined as posttransplant kidney allograft lifespan, of this practice. METHODS: Using data from the Scientific Registry of Transplant Recipients, we compared outcomes for all SLK transplants between January 1, 1995, and December 3, 2014, to their donor-matched kidney used in kidney-alone (Ki) or simultaneous pancreas kidney (SPK) transplants. Primary outcome was kidney allograft lifespan, defined as the time free from death or allograft failure. Secondary outcomes included death and death-censored allograft failure. We adjusted all analyses for donor, transplant, and recipient factors. RESULTS: The adjusted 10-year mean kidney allograft lifespan was higher in Ki/SPK compared with SLK transplants by 0.99 years in the Model for End-stage Liver Disease era and 1.71 years in the pre-Model for End-stage Liver Disease era. Death was higher in SLK recipients relative to Ki/SPK recipients: 10-year cumulative incidences 0.36 (95% confident interval 0.33-0.38) versus 0.19 (95% confident interval 0.17-0.21). CONCLUSIONS: SLK transplantation exemplifies the trade-off between the principles of utility and medical urgency. With each SLK transplantation, about 1 year of allograft lifespan is traded so that sicker patients, that is, SLK transplant recipients, are afforded access to the organ. These data provide a basis against which benefits derived from urgency-based allocation can be measured.


Assuntos
Doença Hepática Terminal/cirurgia , Transplante de Rim/métodos , Transplante de Fígado/métodos , Insuficiência Renal/cirurgia , Adulto , Doença Hepática Terminal/complicações , Doença Hepática Terminal/mortalidade , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Insuficiência Renal/complicações , Insuficiência Renal/mortalidade , Resultado do Tratamento
17.
Liver Transpl ; 22(12): 1710-1719, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27875032

RESUMO

Renal failure is a late consequence of end-stage liver disease (ESLD). Even with liver transplantation, pretransplant renal impairment remains a strong predictor of posttransplant mortality. This review seeks to summarize and critically appraise common therapies used in this setting, including pharmacologic agents, procedures (transjugular intrahepatic portosystemic shunt, renal replacement therapy), and simultaneous liver-kidney transplantation. More experimental extracorporal modalities, eg, albumin dialysis or bioartificial livers, will not be discussed. A brief discussion on the definition and pathophysiologic underpinnings of renal failure in ESLD will be held at the beginning to lay the groundwork for the main section. Liver Transplantation 22 1710-1719 2016 AASLD.


Assuntos
Doença Hepática Terminal/complicações , Transplante de Rim/métodos , Transplante de Fígado/métodos , Derivação Portossistêmica Transjugular Intra-Hepática , Insuficiência Renal/terapia , Terapia de Substituição Renal , Doença Hepática Terminal/cirurgia , Taxa de Filtração Glomerular , Humanos , Imunossupressão/efeitos adversos , Imunossupressão/métodos , Substitutos do Plasma/uso terapêutico , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Fatores de Risco , Vasoconstritores/uso terapêutico
18.
Curr Transplant Rep ; 3: 24-32, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27004159

RESUMO

One third of the kidney transplants performed in the USA come from living kidney donors. The long-term outcome of healthy individuals who donate kidneys is mostly excellent, although recent studies have suggested that living donation is associated with a small absolute increase in the risk of end stage renal failure. Much of our understanding about the progression of kidney disease comes from experimental models of nephron loss. For this reason, living kidney donation has long been of great interest to renal physiologists. This review will summarize the determinants of glomerular filtration and the physiology that underlies post-donation hyperfiltration. We describe the 'remnant kidney' model of kidney disease and the reasons why such progressive kidney disease very rarely ensues in healthy humans following uninephrectomy. We also review some of the methods used to determine glomerular number and size and outline their associations.

19.
Clin J Am Soc Nephrol ; 10(9): 1670-7, 2015 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-25908792

RESUMO

The Best Practice in Live Kidney Donation Consensus Conference held in June of 2014 included the Best Practices in Living Donor Education Workgroup, whose charge was to identify best practice strategies in education of living donors, community outreach initiatives, commercial media, solicitation, and state registries. The workgroup's goal was to identify critical content to include in living kidney donor education and best methods to deliver educational content. A detailed summary of considerations regarding educational content issues for potential living kidney donors is presented, including the consensus that was reached. Educational topics that may require updating on the basis of emerging studies on living kidney donor health outcomes are also presented. Enhancing the educational process is important for increasing living donor comprehension to optimize informed decision-making.


Assuntos
Educação em Saúde , Transplante de Rim/educação , Doadores Vivos/educação , Educação de Pacientes como Assunto/normas , Transplantados/educação , Instituições de Assistência Ambulatorial , Consenso , Medicina Baseada em Evidências , Humanos , Consentimento Livre e Esclarecido , Transplante de Rim/efeitos adversos , Nefrologia , Educação de Pacientes como Assunto/métodos , Diálise Renal , Medição de Risco , Fatores de Tempo
20.
J Clin Invest ; 125(3): 1311-8, 2015 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-25689253

RESUMO

BACKGROUND: Over 5,000 living kidney donor nephrectomies are performed annually in the US. While the physiological changes that occur early after nephrectomy are well documented, less is known about the long-term glomerular dynamics in living donors. METHODS: We enrolled 21 adult living kidney donors to undergo detailed long-term clinical, physiological, and radiological evaluation pre-, early post- (median, 0.8 years), and late post- (median, 6.3 years) donation. A morphometric analysis of glomeruli obtained during nephrectomy was performed in 19 subjects. RESULTS: Donors showed parallel increases in single-kidney renal plasma flow (RPF), renocortical volume, and glomerular filtration rate (GFR) early after the procedure, and these changes were sustained through to the late post-donation period. We used mathematical modeling to estimate the glomerular ultrafiltration coefficient (Kf), which also increased early and then remained constant through the late post-donation study. Assuming that the filtration surface area (and hence, Kf) increased in proportion to renocortical volume after donation, we calculated that the 40% elevation in the single-kidney GFR observed after donation could be attributed exclusively to an increase in the Kf. The prevalence of hypertension in donors increased from 14% in the early post-donation period to 57% in the late post-donation period. No subjects exhibited elevated levels of albuminuria. CONCLUSIONS: Adaptive hyperfiltration after donor nephrectomy is attributable to hyperperfusion and hypertrophy of the remaining glomeruli. Our findings point away from the development of glomerular hypertension following kidney donation. TRIAL REGISTRATION: Not applicable. FUNDING. NIH (R01DK064697 and K23DK087937); Astellas Pharma US; the John M. Sobrato Foundation; the Satellite Extramural Grant Foundation; and the American Society of Nephrology.


Assuntos
Glomérulos Renais/fisiologia , Feminino , Taxa de Filtração Glomerular , Humanos , Doadores Vivos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Nefrectomia
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