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1.
Arch Esp Urol ; 74(3): 293-298, 2021 Apr.
Artigo em Espanhol | MEDLINE | ID: mdl-33818425

RESUMO

OBJECTIVE: Kidney transplant is the treatmentof election of end-stage chronic renal disease, usually being heterotopic extraperitoneal in the iliac fossae, with successful results. This technique can be challenging or even not feasible, usually in cases of severe vasculopathy or previous grafts, so urologists should consider alternatives such as orthotopic transplant. MATERIAL AND METHODS: We present three cases oforthotopic kidney transplant (OKT) made in Cruces University Hospital from 2001 to 2019, out of 2580 cases. We review recipients' medical history, indication,surgical technique and post surgical evolution. RESULTS: The average age of the patients was 51.6 years. The indication was severe vasculopathy of iliac vessels. We made left nephrectomy, followed by venous renal end-to-end anastomosis, arterial end-to-side anastomosis to aorta and pyelo-pyelic anastomosis with catheter,with immediate function of the graft. The patients' evolution was favourable, without significant complications and no differences with heterotopic transplant. CONCLUSION: OKT is a good alternative when heterotopicis not feasible, with an acceptable number of complications and similar survival.


Assuntos
Falência Renal Crônica , Transplante de Rim , Anastomose Cirúrgica , Aorta , Humanos , Rim , Falência Renal Crônica/cirurgia , Pessoa de Meia-Idade
2.
S D Med ; 74(1): 21-27, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33691053

RESUMO

Advances in the field of solid-organ transplantation (SOT), namely evolution of surgical techniques, developments in immunosuppressive therapies and efforts to maximize utilization of donor allografts (deceased and living), have resulted in growing numbers of SOT performed annually in the United States (U.S.) (36,529 total organs and 21,167 kidneys transplanted in 2018). However, the Native American/American Indian (NA/AI) people of the U.S. experience enormous socioeconomic barriers such as poverty, lack of adequate healthcare, poor health literacy and geographic isolation which limit access to SOT resulting in low rates of organ donation and transplantation, poor quality of life and shorter life expectancy. The NA/AI population is at increased risk for end-stage renal disease secondary to the high prevalence of diabetes mellitus. We review existing challenges to kidney transplantation in NA/AI patients and discuss potential solutions which could improve equitable delivery of specialized healthcare to this underprivileged population.


Assuntos
Falência Renal Crônica , Transplante de Rim , Obtenção de Tecidos e Órgãos , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/cirurgia , Qualidade de Vida , Estados Unidos
3.
Medicine (Baltimore) ; 100(6): e24623, 2021 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-33578574

RESUMO

RATIONALE: Acute esophageal necrosis (AEN) is a rare syndrome with characteristic endoscopic and pathologic findings. It usually results from a combination of tissue hypoperfusion, impaired local defense barriers, and massive reflux of gastric contents. We report a case of AEN after a kidney transplant. PATIENT CONCERNS: A 53-year-old man with hypertension and end-stage renal disease presented with abdominal pain and a single episode of hematemesis 14 days after kidney transplantation. DIAGNOSIS: Upper endoscopy revealed circumferential black coloration in the mid to lower esophageal mucosa. Esophageal biopsy showed ulcer, and immunostains were negative for viral etiology. INTERVENTIONS: Conservative management was done with total parenteral nutrition and proton pump inhibitor. OUTCOMES: The patient experienced no further episodes of hematemesis or abdominal pain and follow-up endoscopy showed remarkable changes from the black mucosa to a red friable mucosa with whitish exudates. LESSONS: In the case, AEN occurred in the setting of normal blood pressure after major surgery despite the absence of preceding factors such as hypotension and infections. The possibility of AEN should be considered in patients with solid organ transplantation who present with abdominal pain, dysphagia, and hematemesis.


Assuntos
Esôfago/patologia , Falência Renal Crônica/cirurgia , Transplante de Rim , Necrose/diagnóstico , Diagnóstico Diferencial , Esofagoscopia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico
4.
BMJ Case Rep ; 14(2)2021 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-33558380

RESUMO

Cancers can develop the ability to evade immune recognition and destruction. Immune checkpoint inhibitors (ICIs) are drugs targeting these immune evasion mechanisms. ICIs have significantly improved outcomes in several cancers including metastatic melanoma. However, data on toxicities associated with allograft transplant recipients receiving ICI is limited. We describe a case of a 71-year-old woman who was diagnosed with metastatic melanoma 13 years after renal transplantation. She was commenced on the ICI nivolumab. She developed acute renal transplant rejection 15 days after administration of the first dose. She continues on haemodialysis but has demonstrated complete oncological response. This case demonstrates the risk of acute renal transplant rejection versus improved oncological outcomes. Patients and clinicians must consider this balance when initiating ICI therapy in allograft transplant recipients. Patients should be fully consented of the potential consequences of acute renal transplant rejection including lifelong dialysis.


Assuntos
Antineoplásicos Imunológicos/efeitos adversos , Rejeição de Enxerto/induzido quimicamente , Transplante de Rim , Melanoma/tratamento farmacológico , Nivolumabe/efeitos adversos , Neoplasias Cutâneas/tratamento farmacológico , Idoso , Feminino , Humanos , Falência Renal Crônica/cirurgia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/secundário , Metástase Linfática , Melanoma/patologia , Couro Cabeludo/patologia , Neoplasias Cutâneas/patologia , Fatores de Tempo , Transplante Homólogo
6.
JAMA Netw Open ; 4(1): e2034004, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33443583

RESUMO

Importance: Kidney transplant is associated with improved survival and quality of life among patients with kidney failure; however, significant racial disparities have been noted in transplant access. Common equations that estimate glomerular filtration rate (eGFR) include adjustment for Black race; however, how inclusion of the race coefficient in common eGFR equations corresponds with measured GFR and whether it is associated with delayed eligibility for kidney transplant listing are unknown. Objective: To compare eGFR with measured GFR and evaluate the association between eGFR calculated with vs without a coefficient for race and time to eligibility for kidney transplant. Design, Setting, and Participants: This prospective cohort study used data from the Chronic Renal Insufficiency Cohort, a multicenter cohort study of participants with chronic kidney disease (CKD). Self-identified Black participants from that study were enrolled between April 2003 and September 2008, with follow-up through December 2018. Statistical analyses were completed on November 11, 2020. Exposure: Estimated GFR, measured annually and estimated using the creatinine-based Chronic Kidney Disease-Epidemiology (CKD-EPI) equation with and without a race coefficient. Main Outcomes and Measures: Iothalamate GFR (iGFR) measured in a subset of participants (n = 311) and time to achievement of an eGFR less than 20 mL/min/1.73 m2, an established threshold for kidney transplant referral and listing. Results: Among 1658 self-identified Black participants, mean (SD) age was 58 (11) years, 848 (51%) were female, and mean (SD) eGFR was 44 (15) mL/min/1.73 m2. The CKD-EPI eGFR with the race coefficient overestimated iGFR by a mean of 3.1 mL/min/1.73 m2 (95% CI, 2.2-3.9 mL/min/1.73 m2; P < .001). The mean difference between CKD-EPI eGFR without the race coefficient and iGFR was of smaller magnitude (-1.7 mL/min/1.73 m2; 95% CI, -2.5 to -0.9 mL/min/1.73 m2). For participants with an iGFR of 20 to 25 mL/min/1.73 m2, the mean difference in eGFR with vs without the race coefficient and iGFR was 5.1 mL/min/1.73 m2 (95% CI, 3.3-6.9 mL/min/1.73 m2) vs 1.3 mL/min/1.73 m2 (95% CI, -0.3 to 2.9 mL/min/1.73 m2). Over a median follow-up time of 4 years (interquartile range, 1-10 years), use of eGFR calculated without vs with the race coefficient was associated with a 35% (95% CI, 29%-41%) higher risk of achieving an eGFR less than 20 mL/min/1.73 m2 and a shorter median time to this end point of 1.9 years. Conclusions and Relevance: In this cohort study, inclusion of the race coefficient in the estimation of GFR was associated with greater bias in GFR estimation and with delayed achievement of a clinical threshold for kidney transplant referral and eligibility. These findings suggest that nephrologists and transplant programs should be cautious when using current estimating equations to determine kidney transplant eligibility.


Assuntos
Afro-Americanos , Definição da Elegibilidade , Taxa de Filtração Glomerular , Falência Renal Crônica/etnologia , Falência Renal Crônica/cirurgia , Transplante de Rim , Feminino , Humanos , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida , Washington
7.
J Urol ; 205(4): 1009-1017, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33320719

RESUMO

PURPOSE: Erectile dysfunction has a lower prevalence in renal transplant recipients compared to dialysis patients. Despite this observation, the effect of renal transplantation on erectile function remains unknown. We aimed to assess the role of renal transplantation on erectile function and to determine potential factors improving or deteriorating erectile dysfunction. MATERIALS AND METHODS: We conducted a systematic review and random effects meta-analysis of observational studies comparing erectile function preoperatively and postoperatively in renal transplant recipients (PROSPERO ID: CRD42020189580). Records reporting relevant outcomes were identified through search of PubMed®, Embase®, Cochrane Library and Scopus® databases from inception to September 2020. Judgment of the strength of evidence was performed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: We included 20 studies with 1,695 renal transplant recipients. At postoperative evaluation the number of patients with erectile dysfunction was reduced (RR 1.21, 95% CI 1.02-1.45, I2=88%). Renal transplant recipients reported an improvement in erectile function (RR 2.53, 95% CI 1.44-4.44, I2=90%) and the mean International Index of Erectile Function score increased by 3.04 points (95% CI 0.63-5.45, I2=96%) after renal transplantation. These effects were not demonstrated in the sensitivity analysis. In individuals reporting severe erectile dysfunction, no favorable effect of renal transplantation was observed (RR 1.51, 95% CI 0.85-2.68, I2=33%). For all outcomes the strength of evidence was considered low or very low due to methodological concerns and high heterogeneity among the included studies. CONCLUSIONS: Renal transplantation improves erectile function and the risk of erectile dysfunction reduces postoperatively compared to preoperatively. However, evidence on the matter is mostly based on low quality data. More studies with standardized outcomes are needed to validate and strengthen our findings.


Assuntos
Disfunção Erétil/prevenção & controle , Falência Renal Crônica/cirurgia , Transplante de Rim , Humanos , Masculino
9.
Transplantation ; 105(1): 115-120, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33350626

RESUMO

BACKGROUND: Patients with chronic kidney disease stage 5 and those on immunosuppression are particularly vulnerable and are shielded as per public health strategy. We present our experience of coronavirus disease 2019 (COVID-19) transplant patients in one of the most affected parts of the UK with direct comparison to waitlisted patients. METHODS: A single-center prospective study of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive waitlisted and transplant patients was undertaken to compare these groups and assess clinical outcomes. RESULTS: A total of 60 consecutive symptomatic SARS-CoV-2 positive patients were identified with 32 active waitlisted patients and 28 functioning renal transplants. Demographics were similar. The incidence of symptomatic COVID-19 in the waitlisted group was 9.9% compared to 1.9% in renal transplant patients (P < 0.001). Immunosuppression did not influence initial symptomology. Fifteen percent of patients in the waitlisted and 32% in the transplant groups died (P = 0.726). Mortality as proportion of total waitlisted (321 patients) and transplant population (1434 patients) of our centre was 1.5% and 0.6% (P < 0.001), respectively. C-reactive protein (CRP) at 48 h and peak CRP were associated with mortality in both groups while quick sequential organ failure assessment score at 48 h (P = 0.036) was associated with mortality for transplant patients. CONCLUSIONS: Incidence of COVID-19 is higher in the waitlisted population but transplant patients have more severe disease, reflected by higher mortality. CRP at 48 h can be used as a predictive tool. In the absence of effective treatments, the current strategy of shielding is arguably the most important factor in protecting patients while resuming transplantation.


Assuntos
/epidemiologia , Imunossupressão/métodos , Imunossupressores/uso terapêutico , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Listas de Espera , Adulto , Idoso , Comorbidade , Feminino , Seguimentos , Humanos , Hospedeiro Imunocomprometido , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Prospectivos , RNA Viral/análise , Transplantados
12.
Adv Chronic Kidney Dis ; 27(5): 383-389, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-33308503

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2, has led to the death of hundreds of thousands of people worldwide. If infected, older individuals and those with diabetes, hypertension, cardiovascular disease, and compromised immune systems are at higher risk for unfavorable outcomes. These comorbidities are prevalent in patients with kidney disease, hence the significant burden of COVID-19 on kidney transplant programs. Multiple case series of kidney transplant recipients with COVID-19 have shown increased mortality compared to nontransplant patients. To date, we do not have high-level evidence to inform immunosuppression minimization strategies in infected transplant recipients. Most centers however have adopted early antimetabolite withdrawal in addition to other interventions. This review summarizes the published COVID-19 literature as it relates to outcomes and immunosuppression management in kidney transplant recipients. It also discusses challenges pertaining to pretransplant evaluation and wait-listed patients.


Assuntos
/terapia , Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Falência Renal Crônica/cirurgia , Transplante de Rim , Telemedicina , /mortalidade , Infecção Hospitalar/prevenção & controle , Assistência à Saúde/métodos , Desprescrições , Humanos , Imunossupressão/métodos , Equipamento de Proteção Individual , Cuidados Pré-Operatórios , Listas de Espera
13.
Actas urol. esp ; 44(9): 623-629, nov. 2020. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-198086

RESUMO

ANTECEDENTES: El trasplante renal con variantes anatómicas vasculares sigue siendo un desafío. Debido a su éxito variable en lo que respecta a la función del injerto después del trasplante, estos órganos se descartan frecuentemente, asumiendo de antemano una tasa inasequible de complicaciones vasculares. PACIENTES Y MÉTODOS: Realizamos 3 trasplantes de riñón utilizando órganos de donantes fallecidos que presentaban variantes vasculares (arterias múltiples y venas cortas), incluyendo un riñón en herradura indivisible. Se utilizaron diferentes injertos extraídos de la aorta, la arteria ilíaca común y la vena cava inferior del mismo donante para reconstruir la configuración vascular inicial mediante la creación de conductos arteriales y venosos individuales, con el fin de simplificar la anastomosis vascular en el receptor. RESULTADOS: No se registraron complicaciones postoperatorias. Los tiempos de isquemia caliente fueron comparables con los de aloinjertos renales de una sola arteria. En ningún caso se observó un retraso en la función del injerto y todos los pacientes recuperaron la función renal normal después del trasplante. CONCLUSIONES: La reconstrucción vascular mediante injertos arteriales y venosos del mismo donante fallecido puede ser un recurso útil para simplificar la anastomosis vascular durante la cirugía de trasplante, evitando así su descarte de antemano, reduciendo al mínimo las complicaciones perioperatorias y permitiendo tasas normales de función de los injertos en el seguimiento a largo plazo. El resultado satisfactorio obtenido mediante la utilización de este enfoque ayudaría a ampliar los criterios de donantes para incluir órganos que presentan variantes anatómicas vasculares


BACKGROUND: Transplantation of kidneys with vascular anatomical variants remains a challenge. Due to its varying success in regard to graft function after transplantation, these organs have been frequently discarded assuming in advance an unaffordable rate of vascular complications. PATIENTS AND METHODS: We performed three kidney transplants using organs from deceased donors harboring vascular variants (multiple arteries and short veins), including an unsplittable horseshoe kidney. Different grafts harvested from the same donor aorta, common iliac artery, and inferior vena cava, were used to reconstruct the initial vascular configuration by creating single arterial and venous conduits aimed to simplify the vascular anastomoses in the recipient. RESULTS: No post-operative complications were recorded. Warm ischemia times remained comparable to single artery renal allografts. No delayed graft function was noted in any case, and every patient regained normal renal function after transplantation. CONCLUSIONS: Vascular reconstruction using arterial and venous grafts harvested from the same deceased donor may result a helpful tool to simplify vascular anastomoses during transplantation surgery, thus avoiding their discard in advance, minimizing perioperative complications, and enabling normal graft function rates in the long-term follow-up. The successful outcome obtained by using this approach would help to expand the donor criteria for the inclusion of organs containing vascular anatomical variants


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Rim/irrigação sanguínea , Artéria Renal/transplante , Cadáver , Derivação Arteriovenosa Cirúrgica/métodos , Aloenxertos , Resultado do Tratamento , Veia Cava Inferior/transplante , Artéria Ilíaca/transplante , Aorta Abdominal/transplante
15.
BMC Nephrol ; 21(1): 419, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33004002

RESUMO

BACKGROUND: Infection with the severe acute respiratory coronavirus 2 (SARS-CoV-2) has led to a worldwide pandemic with coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, overwhelming healthcare systems globally. Preliminary reports suggest a high incidence of infection and mortality with SARS-CoV-2 in patients receiving kidney replacement therapy (KRT). The aims of this study are to report characteristics, rates and outcomes of all patients affected by infection with SARS-CoV-2 undergoing KRT in Scotland. METHODS: Study design was an observational cohort study. Data were linked between the Scottish Renal Registry, Health Protection Scotland and the Scottish Intensive Care Society Audit Group national data sets using a unique patient identifier (Community Health Index (CHI)) for each individual by the Public Health and Intelligence unit of Public Health, Scotland. Descriptive statistics and survival analyses were performed. RESULTS: During the period 1st March 2020 to 31st May 2020, 110 patients receiving KRT tested positive for SARS-CoV-2 amounting to 2% of the prevalent KRT population. Of those affected, 86 were receiving haemodialysis or peritoneal dialysis and 24 had a renal transplant. Patients who tested positive were older and more likely to reside in more deprived postcodes. Mortality was high at 26.7% in the dialysis patients and 29.2% in the transplant patients. CONCLUSION: The rate of detected SARS-CoV-2 in people receiving KRT in Scotland was relatively low but with a high mortality for those demonstrating infection. Although impossible to confirm, it appears that the measures taken within dialysis units coupled with the national shielding policy, have been effective in protecting this population from infection.


Assuntos
Betacoronavirus/isolamento & purificação , Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus , Falência Renal Crônica , Transplante de Rim/estatística & dados numéricos , Pandemias , Pneumonia Viral , Terapia de Substituição Renal , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/cirurgia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Saúde Pública/métodos , Sistema de Registros/estatística & dados numéricos , Terapia de Substituição Renal/métodos , Terapia de Substituição Renal/estatística & dados numéricos , Escócia/epidemiologia
17.
Medicine (Baltimore) ; 99(38): e22300, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957390

RESUMO

INTRODUCTION: Bardet-Biedl syndrome, which compromises airway management and the cardiovascular and renal systems, is a rare ciliopathic syndrome characterized by multisystem involvement and varying genetic etiologies and clinical manifestations. PATIENT CONCERNS: A 13-year-old female patient had a history of chronic renal failure, hypothyroidism, mental retardation, hypogonadotropic hypogonadism, obesity, and retinitis pigmentosa and was undergoing 4-hour hemodialysis 3 days a week. DIAGNOSIS: We diagnosed Bardet-Biedl syndrome based on the results of genetic tests. INTERVENTIONS: We performed renal transplantation under general anesthesia while considering the perioperative risks of airway obstruction and hypothermia. OUTCOMES: Multidisciplinary preoperative evaluation is crucial to avoid perioperative complications. The risk of an obstructed airway should be considered. Hypothyroidism is a rare consequence of Bardet-Biedl syndrome. Rocuronium and sugammadex are safe for anesthetic management during renal transplantation to address Bardet-Biedl syndrome. CONCLUSION: Safe anesthetic management can be achieved with the rigorous preoperative assessment of perioperative complications.


Assuntos
Anestesia Geral/métodos , Síndrome de Bardet-Biedl/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Anormalidades Múltiplas/etiologia , Adolescente , Feminino , Humanos , Falência Renal Crônica/diagnóstico por imagem , Falência Renal Crônica/etiologia , Cuidados Pré-Operatórios
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