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2.
Medicine (Baltimore) ; 99(51): e23584, 2020 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-33371088

RESUMO

ABSTRACT: To compare the difference between University of Wisconsin (UW) solution and histidine-tryptophan-ketoglutarate (HTK) solution in adult living donor liver transplantation (LDLT).This study included LDLT patients at the Liver Transplantation Center of West China Hospital of Sichuan University from November 2001 to June 2018. These patients were classified into 2 groups depending on the use of the different preservation solutions, and the confounding factors between the 2 groups were eliminated by propensity score matching. Finally, the incidence of complications; serum examination at postoperative days 1, 3, 5, 7, 14, 21, and 30; and the overall survival rate of the 2 groups were compared to observe whether there were any differences between the 2 preservation solutions.Of the 298 patients we screened, 170 were treated with UW solution and 128 with HTK solution. After propensity score matching, 106 pairs of patients were selected. In the comparison of the 2 groups, the length of intensive care unit stay in the UW group was significantly longer than that in the HTK group (P = .022), but there was no difference in the total length of hospital stay between the 2 groups (P = .277). No statistically significant difference was observed in the 2 groups in terms of the incidence of complications or postoperative examinations. However, the incidence of early allograft dysfunction in the HTK group was slightly lower than that in the UW group (HTK: UW = 14.1%: 20.7%), although the difference was not statistically significant. In terms of the overall survival rate, the 1, 3, and 5-year survival rates of the HTK group were 85.5%, 70.2%, and 65.1%, respectively, while the 1, 3, and 5-year survival rates of the UW group were 83.1%, 67.2%, and 59.8%, respectively, and there was no significant difference between the 2 groups.In conclusion, our study shows that UW solution and HTK solution are equivalent in perioperative safety, the recovery of transplanted liver function, the occurrence of postoperative complications and overall survival and can be safely and effectively applied in adult LDLT. If economic factors are taken into account, HTK can save costs to a certain extent.


Assuntos
Transplante de Fígado/métodos , Soluções para Preservação de Órgãos/uso terapêutico , Adenosina/uso terapêutico , Adulto , Alopurinol/uso terapêutico , China , Feminino , Glucose/uso terapêutico , Glutationa/uso terapêutico , Rejeição de Enxerto/epidemiologia , Humanos , Insulina/uso terapêutico , Tempo de Internação , Transplante de Fígado/mortalidade , Doadores Vivos , Masculino , Manitol/uso terapêutico , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Cloreto de Potássio/uso terapêutico , Procaína/uso terapêutico , Pontuação de Propensão , Rafinose/uso terapêutico , Análise de Sobrevida
3.
Medicine (Baltimore) ; 99(51): e23750, 2020 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-33371134

RESUMO

ABSTRACT: Although pediatric split liver transplantation (SLT) has been proven safe and the waitlist mortality rate has been successfully reduced, the safety of adult SLT has not been confirmed.Using 1:2 matching, 47 recipients who underwent adult SLT were matched to 94 of 743 recipients who underwent adult whole graft liver transplantation (WGLT). Eventually, 141 recipients were included in the case-control study. Subgroup analysis of 43 recipients in the SLT group was performed based on the presence of the middle hepatic vein (MHV) in the grafts.No significant differences in 5-year survival (80.8% vs 81.6%, P = .465) were observed between the adult SLT and WGLT groups. However, compared to recipients in the WGLT group, those in the SLT group had more Clavien-Dindo grade III-V complications, longer hospitalization duration, and higher mortality within 45 days. Furthermore, on multivariate analysis, 45-day postoperative mortality in recipients in the SLT group was mainly affected by hyperbilirubinemia within postoperative day (POD) 7-14, surgery time, and intraoperative blood loss. Subgroup analysis showed no significant differences in hyperbilirubinemia within POD 7-14, complications, and survival rate between SLTMHV(+) and SLTMHV [-].Adult SLT is safe and effective based on long-term survival rates; however, a reduction in the incidence of short-term complications is required. Non-obstructive hyperbilirubinemia within POD 7 to 14 is an independent predictor of short-term mortality after SLT.


Assuntos
Transplante de Fígado/métodos , Estudos de Casos e Controles , Feminino , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto/fisiologia , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Testes de Função Hepática , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença
4.
Isr Med Assoc J ; 9(22): 486-490, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32954694

RESUMO

OBJECTIVES: To investigate the impact of recipient age on the occurrence of rejections, vasculopathy, and mortality after HTx. METHODS: Study population comprised all consecutive 291 patients who underwent HTx between 1991-2016 and were followed at our center. Patients were categorized by age tertiles: < 46 years (mean 31.4 ± 11.7, range 16-45, n=90), 46-57 years (mean 51.4 ± 3.2, range 46-56, n=92), and ≥ 57 years (mean 61.6 ± 3.4, range 57-73, n=109). RESULTS: Patients aged ≥ 57 years were more often males and had more pre-HTx co-morbidities including hypertension, diabetes, dyslipidemia, and history of smoking (P < 0.05) compared to the younger age groups. Kaplan-Meier analysis by age tertiles showed the rates of major rejections and vasculopathy at 15 years were similar among the three age groups. Mortality rates at 15 years were directly related to the age groups (39%, 52%, 62% log-rank, P = 0.01). However, the association between age and mortality was no longer statistically significant after multivariate analysis (hazard ratio 1.01, 95% confidence interval 1.00-1.03). CONCLUSIONS: In a contemporary cohort of patients undergoing HTx, recipient age does not significantly impact the risk of major rejections, vasculopathy, and long-term mortality.


Assuntos
Rejeição de Enxerto/epidemiologia , Transplante de Coração/estatística & dados numéricos , Seleção de Pacientes , Adolescente , Adulto , Fatores Etários , Idoso , Estudos de Coortes , Feminino , Transplante de Coração/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Adulto Jovem
6.
Transplantation ; 104(8): 1553-1559, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732831

RESUMO

Although over 90 000 people are on the kidney transplant waitlist in the United States, some kidneys that are viable for transplantation are discarded. Transplant surgeons are more likely to discard deceased donors with acute kidney injury (AKI) versus without AKI (30% versus 18%). AKI is defined using changes in creatinine from baseline. Transplant surgeons can use DonorNet data, including admission, peak, and terminal serum creatinine, and biopsy data when available to differentiate kidneys with AKI from those with chronic injury. Although chronic kidney disease is associated with reduced graft survival, an abundance of literature has demonstrated similar graft survival for deceased donors with AKI versus donors without AKI. Donors with AKI are more likely to undergo delayed graft function but have similar long-term outcomes as donors without AKI. The mechanism for similar graft survival is unclear. Some hypothesized mechanisms include (1) ischemic preconditioning; (2) posttransplant and host factors playing a greater role in long-term survival than donor factors; and (3) selection bias of transplanting only relatively healthy donor kidneys with AKI. Existing literature suggests transplanting more donor kidneys with stage 1 and 2 AKI, and cautious utilization of stage 3 AKI donors, may increase the pool of viable kidneys. Doing so can reduce the number of people who die on the waitlist by over 500 every year.


Assuntos
Lesão Renal Aguda/diagnóstico , Função Retardada do Enxerto/epidemiologia , Seleção do Doador/métodos , Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Lesão Renal Aguda/sangue , Lesão Renal Aguda/patologia , Aloenxertos/patologia , Aloenxertos/fisiopatologia , Aloenxertos/provisão & distribução , Biomarcadores/análise , Biópsia , Creatinina/sangue , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/fisiopatologia , Seleção do Doador/normas , Taxa de Filtração Glomerular/fisiologia , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Sobrevivência de Enxerto/fisiologia , Humanos , Rim/patologia , Rim/fisiopatologia , Transplante de Rim/efeitos adversos , Transplante de Rim/normas , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos/epidemiologia
7.
Transplantation ; 104(8): 1591-1603, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732836

RESUMO

BACKGROUND: Combined liver-kidney transplantation (CLKT) improves survival for liver transplant recipients with renal dysfunction; however, the tenuous perioperative hemodynamic and metabolic milieu in high-acuity CLKT recipients increases delayed graft function and kidney allograft failure. We sought to analyze whether delayed KT through pumping would improve kidney outcomes following CLKT. METHODS: A retrospective analysis (University of California Los Angeles [n = 145], Houston Methodist Hospital [n = 79]) was performed in all adults receiving CLKT at 2 high-volume transplant centers from February 2004 to January 2017, and recipients were analyzed for patient and allograft survival as well as renal outcomes following CLKT. RESULTS: A total of 63 patients (28.1%) underwent delayed implantation of pumped kidneys during CLKT (dCLKT) and 161 patients (71.9%) received early implantation of nonpumped kidneys during CLKT (eCLKT). Most recipients were high-acuity with median biologic model of end-stage liver disease (MELD) score of, 35 for dCLKT and 34 for eCLKT (P = ns). Pretransplant, dCLKT had longer intensive care unit stay, were more often intubated, and had greater vasopressor use. Despite this, dCLKT exhibited improved 1-, 3-, and 5-year patient and kidney survival (P = 0.02) and decreased length of stay (P = 0.001), kidney allograft failure (P = 0.012), and dialysis duration (P = 0.031). This reduced kidney allograft futility (death or continued need for hemodialysis within 3 mo posttransplant) for dCLKT (6.3%) compared with eCLKT (19.9%) (P = 0.013). CONCLUSIONS: Delayed implantation of pumped kidneys is associated with improved patient and renal allograft survival and decreased hospital length of stay despite longer kidney cold ischemia. These data should inform the ethical debate as to the futility of performing CLKT in high-acuity recipients.


Assuntos
Doença Hepática Terminal/cirurgia , Rejeição de Enxerto/epidemiologia , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Preservação de Órgãos/métodos , Idoso , Aloenxertos/imunologia , Aloenxertos/provisão & distribução , Isquemia Fria/instrumentação , Isquemia Fria/métodos , Isquemia Fria/estatística & dados numéricos , Doença Hepática Terminal/complicações , Estudos de Viabilidade , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/imunologia , Humanos , Rim/imunologia , Transplante de Rim/ética , Transplante de Rim/métodos , Transplante de Rim/estatística & dados numéricos , Transplante de Fígado/ética , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Masculino , Futilidade Médica/ética , Pessoa de Meia-Idade , Preservação de Órgãos/instrumentação , Preservação de Órgãos/estatística & dados numéricos , Perfusão/instrumentação , Perfusão/métodos , Perfusão/estatística & dados numéricos , Insuficiência Renal/etiologia , Insuficiência Renal/cirurgia , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Transplante Homólogo/efeitos adversos , Transplante Homólogo/ética , Transplante Homólogo/métodos , Resultado do Tratamento
8.
Transplantation ; 104(8): 1604-1611, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732837

RESUMO

BACKGROUND: Donor livers with ≥30% macrosteatosis (steatotic livers) represent a possible expansion to the donor pool, but are frequently discarded as they are associated with an increased risk of mortality and graft loss. We hypothesized that there are certain recipient phenotypes that would tolerate donor steatosis well, and are therefore best suited to receive these grafts. METHODS: Using national registry data from the Scientific Registry of Transplant Recipients between 2006 and 2017, we compared 2048 liver transplant recipients of steatotic livers with 69 394 recipients of nonsteatotic (<30%) livers. We identified recipient factors that amplified the impact of donor steatosis on mortality and graft loss using interaction analysis, classifying recipients without these factors as preferred recipients. We compared mortality and graft loss with steatotic versus nonsteatotic livers in preferred and nonpreferred recipients using Cox regression. RESULTS: Preferred recipients of steatotic livers were determined to be first-time recipients with a model for end-stage liver disease 15-34, without primary biliary cirrhosis, and not on life support before transplant. Preferred recipients had no increased mortality risk (hazard ratio [HR]: 0.921.041.16; P = 0.5) or graft loss (HR: 0.931.031.15; P = 0.5) with steatotic versus nonsteatotic livers. Conversely, nonpreferred recipients had a 41% increased mortality risk (HR: 1.171.411.70; P < 0.001) and 39% increased risk of graft loss (HR: 1.161.391.66; P < 0.001) with steatotic versus nonsteatotic livers. CONCLUSIONS: The risks of liver transplantation with steatotic donor livers could be minimized by appropriate recipient matching.


Assuntos
Doença Hepática Terminal/cirurgia , Fígado Gorduroso/diagnóstico , Rejeição de Enxerto/epidemiologia , Transplante de Fígado/efeitos adversos , Seleção de Pacientes , Adulto , Idoso , Aloenxertos/patologia , Aloenxertos/provisão & distribução , Modificador do Efeito Epidemiológico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Fígado Gorduroso/patologia , Feminino , Rejeição de Enxerto/patologia , Rejeição de Enxerto/prevenção & controle , Rejeição de Enxerto/cirurgia , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Fígado/patologia , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Medição de Risco , Índice de Gravidade de Doença , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia
9.
Transplantation ; 104(8): e236-e242, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732842

RESUMO

BACKGROUND: Proper care of young children in need of kidney transplant (KT) requires many skilled professionals and an expensive hospital structure. Small children have lesser access to KT. METHODS: We describe a strategy performed in Brazil to enable and accelerate KT in children ≤15 kg based on the establishment of one specialized transplant center, focused on small children, and cooperating with distant centers throughout the country. Actions on 3 fronts were implemented: (a) providing excellent medical assistance, (b) coordinating educational activities to disseminate expertise and establish a professional network, and (c) fostering research to promote scientific knowledge. We presented the number and outcomes of small children KT as a result of this strategy. RESULTS: Three hundred forty-six pediatric KTs were performed in the specialized center from 2009 to 2017, being 130 in children ≤15 kg (38%, being 41 children ≤10 kg) and 216 in >15 kg (62%). Patient survival after 1 and 5 years of the transplant was 97% and 95% in the "small children" group, whereas, in the "heavier children" group, it was 99% and 96% (P = 0.923). Regarding graft survival, we observed in the "small children" group, 91% and 87%, whereas in the "heavier children" group, 94% and 87% (P = 0.873). These results are comparable to the literature data. Groups were similar in the incidence of reoperation, vascular thrombosis, posttransplant lymphoproliferative disease, and estimated glomerular filtration rate. CONCLUSIONS: The strategy allowed an improvement in the number of KT in small children with excellent results. We believe this experience may be useful in other locations.


Assuntos
Rejeição de Enxerto/epidemiologia , Hospitais Pediátricos/organização & administração , Falência Renal Crônica/cirurgia , Transplante de Rim/estatística & dados numéricos , Tempo para o Tratamento/organização & administração , Adolescente , Peso Corporal/fisiologia , Brasil/epidemiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Sobrevivência de Enxerto/fisiologia , Implementação de Plano de Saúde , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Incidência , Falência Renal Crônica/mortalidade , Falência Renal Crônica/fisiopatologia , Transplante de Rim/efeitos adversos , Masculino , Avaliação de Programas e Projetos de Saúde , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
10.
Transplantation ; 104(8): 1654-1661, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732844

RESUMO

BACKGROUND: In the United Kingdom, 1 in 3 patients on the National Kidney Transplant Waiting List (NKTWL) is suspended from the list at least once during their wait. The mortality of this large cohort of patients remains underreported and poorly described. METHODS: We linked patient records from the UK transplant registry to mortality data from the Office of National Statistics and evaluated the impact of a clinically induced suspension event by estimating hazard ratios (HRs) that compared mortality and graft survival between those who had experienced a suspension event and those who had not. RESULTS: Between January 1, 2000, and December 31, 2010, 16.7% (2221/13 322) of all patients registered on the NKTWL were suspended. Forty-eight percent (588/1225) of those who were suspended and who were never transplanted died, most often from cardiothoracic causes. A suspension event was associated with increased mortality from the time of listing (adjusted HR [aHR], 1.79; 1.64-1.95) and from the time of transplantation (aHR, 1.20; 1.06-1.37; P = 0.005). Graft survival was also poorer in those who had been suspended (aHR, 1.13; 1.01-1.28; P = 0.04). CONCLUSIONS: Patients suspended on the NKTWL have a significantly higher rate of mortality both on the waiting list and following transplantation. Earlier prioritization of patients at risk of experiencing a suspension event may improve their outcomes.


Assuntos
Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Seleção de Pacientes , Listas de Espera/mortalidade , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Humanos , Estimativa de Kaplan-Meier , Falência Renal Crônica/mortalidade , Transplante de Rim/normas , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Alocação de Recursos/normas , Alocação de Recursos/estatística & dados numéricos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
11.
Transplantation ; 104(8): 1675-1685, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732847

RESUMO

BACKGROUND: The incidence of pregnancy in kidney transplantation (KT) recipients is increasing. Studies report that the incidence of graft loss (GL) during pregnancy is low, but less data are available on long-term effects of pregnancy on the graft. METHODS: Therefore, we performed a meta-analysis and systematic review on GL and graft function, measured by serum creatinine (SCr), after pregnancy in KT recipients, stratified in years postpartum. Furthermore, we included studies of nulliparous KT recipients. RESULTS: Our search yielded 38 studies on GL and 18 studies on SCr. The pooled incidence of GL was 9.4% within 2 years after pregnancy, 9.2% within 2-5 years, 22.3% within 5-10 years, and 38.5% >10 years postpartum. In addition, our data show that, in case of graft survival, SCr remains stable over the years. Only within 2 years postpartum, Δ SCr was marginally higher (0.18 mg/dL, 95%CI [0.05-0.32], P = 0.01). Furthermore, no differences in GL were observed in 10 studies comparing GL after pregnancy with nulliparous controls. Systematic review of the literature showed that mainly prepregnancy proteinuria, hypertension, and high SCr are risk factors for GL. CONCLUSIONS: Overall, these data show that pregnancy after KT has no effect on long-term graft survival and only a possible effect on graft function within 2 years postpartum. This might be due to publication bias. No significant differences were observed between pre- and postpartum SCr at longer follow-up intervals.


Assuntos
Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto/fisiologia , Transplante de Rim/efeitos adversos , Período Pós-Parto/fisiologia , Complicações na Gravidez/epidemiologia , Feminino , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Humanos , Gravidez , Complicações na Gravidez/etiologia , Complicações na Gravidez/fisiopatologia , Fatores de Risco
12.
Transplantation ; 104(8): 1720-1725, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732852

RESUMO

BACKGROUND: The impact of opioid use in lung transplant candidates on posttransplant outcomes is unknown. Studies on opioid therapy in kidney and liver transplant candidates have suggested increased risk of graft failure or death. We sought to analyze the relationship between pretransplant opioid use in lung transplant candidates and retransplant-free survival. METHODS: We retrospectively reviewed adult patients transplanted consecutively between November 2004 and August 2015. The exposure was any opioid use at time of transplant listing and primary outcome was retransplant-free survival, analyzed via Cox regression model adjusted for recipient age, gender, ethnicity, diagnosis, and bridging status. Secondary outcomes included duration of ventilation, intensive care unit and hospital length of stay, 3-month and 1-year survival, continuing opioid use at 1 year, and time to onset of chronic lung allograft dysfunction. RESULTS: The prevalence of opioid use at time of listing was 14% (61/425). Median daily oral morphine equivalent dose was 31 mg (18-54). Recipient ethnicity was associated with pretransplant opioid use. Opioid use at time of listing did not increase risk of death or retransplantation in an adjusted model (hazard ratio 1.12 [95% confidence interval 0.65-1.83], P = 0.6570). Secondary outcomes were similar between groups except hospital length of stay (opioid users 35 versus nonusers 27 d, P = 0.014). Continued opioid use at 1-year posttransplant was common (27/56, 48%). CONCLUSIONS: Pretransplant opioid use was not associated with retransplant-free survival in our cohort and should not necessarily preclude listing. Further work stratifying opioid use by indication and the association with opioid use disorder would be worthwhile.


Assuntos
Analgésicos Opioides/efeitos adversos , Rejeição de Enxerto/epidemiologia , Pneumopatias/cirurgia , Transplante de Pulmão/efeitos adversos , Dor/tratamento farmacológico , Adulto , Aloenxertos/efeitos dos fármacos , Aloenxertos/fisiopatologia , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Seguimentos , Volume Expiratório Forçado/efeitos dos fármacos , Volume Expiratório Forçado/fisiologia , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/fisiopatologia , Rejeição de Enxerto/cirurgia , Sobrevivência de Enxerto/efeitos dos fármacos , Sobrevivência de Enxerto/fisiologia , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Pulmão/efeitos dos fármacos , Pulmão/fisiopatologia , Pneumopatias/complicações , Pneumopatias/mortalidade , Transplante de Pulmão/normas , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Período Pré-Operatório , Modelos de Riscos Proporcionais , Sistema de Registros/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
13.
Transplantation ; 104(8): 1738-1745, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732854

RESUMO

BACKGROUND: Falls occur in 28% of hemodialysis patients and increase the risk of physical impairment, morbidity, and mortality. Therefore, it is likely that kidney transplantation (KT) candidates with recurrent falls are less likely to access KT and more likely to experience adverse post-KT outcomes. METHODS: We used a 2-center cohort study of KT candidates (n = 3666) and recipients (n = 770) (January 2009 to January 2018). Among candidates, we estimated time to listing, waitlist mortality, and transplant rate by recurrent falls (≥2 falls) before evaluation using adjusted regression. Among KT recipients, we estimated risk of mortality, graft loss, and length of stay by recurrent falls before KT using adjusted regression. RESULTS: Candidates with recurrent falls (6.5%) had a lower chance of listing (adjusted hazard ratio [aHR] = 0.68, 95% confidence interval [CI], 0.56-0.83) but not transplant rate; waitlist mortality was 31-fold (95% CI, 11.33-85.93) higher in the first year and gradually decreased over time. Recipients with recurrent falls (5.1%) were at increased risk of mortality (aHR = 51.43, 95% CI, 16.00-165.43) and graft loss (aHR = 33.57, 95% CI, 11.25-100.21) in the first year, which declined over time, and a longer length of stay (adjusted relative ratio [aRR] = 1.13, 95% CI, 1.03-1.25). In summary, 6.5% of KT candidates and 5.1% of recipients experienced recurrent falls which were associated with adverse pre- and post-KT outcomes. CONCLUSIONS: While recurrent falls were relatively rare in KT candidates and recipients, they were associated with adverse outcomes. Transplant centers should consider employing fall prevention strategies for high-risk candidates as part of comprehensive prehabilitation.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Rejeição de Enxerto/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Acidentes por Quedas/prevenção & controle , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Transplante de Rim/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Recidiva , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Listas de Espera/mortalidade
14.
Nephrol Dial Transplant ; 35(7): 1250-1261, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32678882

RESUMO

BACKGROUND: Kidney graft recipients receiving immunosuppressive therapy may be at heightened risk for coronavirus disease 2019 (Covid-19) and adverse outcomes. It is therefore important to characterize the clinical course and outcome of Covid-19 in this population and identify safe therapeutic strategies. METHODS: We performed a retrospective chart review of 73 adult kidney graft recipients evaluated for Covid-19 from 13 March to 20 April 2020. Primary outcomes included recovery from symptoms, acute kidney injury, graft failure and case fatality rate. RESULTS: Of the 73 patients screened, 54 tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-39 with moderate to severe symptoms requiring hospital admission and 15 with mild symptoms managed in the ambulatory setting. Hospitalized patients were more likely to be male, of Hispanic ethnicity and to have cardiovascular disease. In the hospitalized group, tacrolimus dosage was reduced in 46% of patients and mycophenolate mofetil (MMF) therapy was stopped in 61% of patients. None of the ambulatory patients had tacrolimus reduction or discontinuation of MMF. Azithromycin or doxycycline was prescribed at a similar rate among hospitalized and ambulatory patients (38% versus 40%). Hydroxychloroquine was prescribed in 79% of hospitalized patients. Graft failure requiring hemodialysis occurred in 3 of 39 hospitalized patients (8%) and 7 patients died, resulting in a case fatality rate of 13% among Covid-19-positive patients and 18% among hospitalized Covid-19-positive patients. CONCLUSIONS: Data from our study suggest that a strategy of systematic triage to outpatient or inpatient care, early management of concurrent bacterial infections and judicious adjustment of immunosuppressive drugs rather than cessation is feasible in kidney transplant recipients with Covid-19.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Rejeição de Enxerto/terapia , Hidroxicloroquina/uso terapêutico , Imunossupressão/métodos , Transplante de Rim , Ácido Micofenólico/uso terapêutico , Pneumonia Viral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Aloenxertos , Antimaláricos/uso terapêutico , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/epidemiologia , Inibidores Enzimáticos/uso terapêutico , Feminino , Rejeição de Enxerto/complicações , Rejeição de Enxerto/epidemiologia , Humanos , Imunossupressores/uso terapêutico , Incidência , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/epidemiologia , Estudos Retrospectivos , Transplantados
15.
PLoS One ; 15(7): e0236396, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32702043

RESUMO

INTRODUCTION: Certain ABO blood types have been linked to cardiovascular disease, infection and cancers. The effect of recipient ABO blood group on patient and graft survival has not been studied in ABO-matched kidney transplantation. This study aims to determine the association between kidney transplant recipient ABO blood groups with patient and graft survival in Australian and New Zealand. METHODS: All Australian and New Zealand transplant recipients who received ABO-compatible primary kidney transplants between 1995-2016 were analysed using a de-identified dataset from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Primary analysis was undertaken of recipient ABO blood group O versus non-O blood groups. The primary outcome was patient survival post kidney transplantation and the secondary outcome was death censored graft survival. Recipient age at first transplant, gender, ethnicity, body mass index, smoking status, vascular disease, presence of diabetes mellitus, chronic lung disease, primary kidney disease, donor source, donor age and gender, and era of transplants were included in the multivariate model as confounders. RESULTS AND CONCLUSIONS: On analysis of 15,523 kidney transplant recipients, blood group O was not associated with patient survival (hazard ratio (HR) 0.96, 95% confidence interval (CI) 0.89-1.04) nor death censored graft survival (HR 0.97, 95% CI 0.89-1.05) compared to non-blood group O recipients. Competing risks analyses showed an increased risk of cancer-related mortality in blood group O recipients on univariate analyses (HR 1.18, 95% CI 1.01-1.37) however, this became insignificant on multivariate analyses. On secondary analyses, recipient blood group AB (4.11% participants) was associated with inferior death censored graft survival compared to those with blood group O (HR 1.24, 95% CI 1.02-1.50). Although recipient ABO blood groups were not associated with patient nor graft survival, differences in cause-specific mortality between individual blood groups cannot be excluded based on current analyses.


Assuntos
Sistema ABO de Grupos Sanguíneos/genética , Incompatibilidade de Grupos Sanguíneos/epidemiologia , Sobrevivência de Enxerto/genética , Transplante de Rim/métodos , Rim/patologia , Adolescente , Adulto , Austrália/epidemiologia , Incompatibilidade de Grupos Sanguíneos/sangue , Tipagem e Reações Cruzadas Sanguíneas , Feminino , Rejeição de Enxerto/sangue , Rejeição de Enxerto/epidemiologia , Humanos , Estimativa de Kaplan-Meier , Rim/cirurgia , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Transplantados , Adulto Jovem
17.
Transplantation ; 104(7): 1305-1307, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32568998
19.
Am J Respir Crit Care Med ; 202(4): 576-585, 2020 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-32379979

RESUMO

Rationale: Acute rejection, manifesting as lymphocytic inflammation in a perivascular (acute perivascular rejection [AR]) or peribronchiolar (lymphocytic bronchiolitis [LB]) distribution, is common in lung transplant recipients and increases the risk for chronic graft dysfunction.Objectives: To evaluate clinical factors associated with biopsy-proven acute rejection during the first post-transplant year in a present-day, five-center lung transplant cohort.Methods: We analyzed prospective diagnoses of AR and LB from over 2,000 lung biopsies in 400 newly transplanted adult lung recipients. Because LB without simultaneous AR was rare, our analyses focused on risk factors for AR. Multivariable Cox proportional hazards models were used to assess donor and recipient factors associated with the time to the first AR occurrence.Measurements and Main Results: During the first post-transplant year, 53.3% of patients experienced at least one AR episode. Multivariable proportional hazards analyses accounting for enrolling center effects identified four or more HLA mismatches (hazard ratio [HR], 2.06; P ≤ 0.01) as associated with increased AR hazards, whereas bilateral transplantation (HR, 0.57; P ≤ 0.01) was associated with protection from AR. In addition, Wilcoxon rank-sum analyses demonstrated bilateral (vs. single) lung recipients, and those with fewer than four (vs. more than four) HLA mismatches demonstrated reduced AR frequency and/or severity during the first post-transplant year.Conclusions: We found a high incidence of AR in a contemporary multicenter lung transplant cohort undergoing consistent biopsy sampling. Although not previously recognized, the finding of reduced AR in bilateral lung recipients is intriguing, warranting replication and mechanistic exploration.


Assuntos
Bronquiolite/epidemiologia , Rejeição de Enxerto/epidemiologia , Transplante de Pulmão , Complicações Pós-Operatórias/epidemiologia , Doença Aguda , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo
20.
Transplantation ; 104(6): 1294-1303, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32433232

RESUMO

BACKGROUND: Hepatitis C virus-positive (HCV+) kidney transplant (KT) recipients are at increased risks of rejection and graft failure. The optimal induction agent for this population remains controversial, particularly regarding concerns that antithymocyte globulin (ATG) might increase HCV-related complications. METHODS: Using Scientific Registry of Transplant Recipients and Medicare claims data, we studied 6780 HCV+ and 139 681 HCV- KT recipients in 1999-2016 who received ATG or interleukin-2 receptor antagonist (IL2RA) for induction. We first examined the association of recipient HCV status with receiving ATG (versus IL2RA) using multilevel logistic regression. Then, we studied the association of ATG (versus IL2RA) with KT outcomes (rejection, graft failure, and death) and hepatic complications (liver transplant registration and cirrhosis) among HCV+ recipients using logistic and Cox regression. RESULTS: HCV+ recipients were less likely to receive ATG than HCV- recipients (living donor, adjusted odds ratio [aOR] = 0.640.770.91; deceased donor, aOR = 0.710.810.92). In contrast, HCV+ recipients who received ATG were at lower risk of acute rejection compared to those who received IL2RA (1-y crude incidence = 11.6% versus 12.6%; aOR = 0.680.820.99). There was no significant difference in the risks of graft failure (adjusted hazard ratio [aHR] = 0.861.001.17), death (aHR = 0.850.951.07), liver transplant registration (aHR = 0.580.971.61), and cirrhosis (aHR = 0.730.921.16). CONCLUSIONS: Our findings suggest that ATG, as compared to IL2RA, may lower the risk of acute rejection without increasing hepatic complications in HCV+ KT recipients. Given the higher rates of acute rejection in this population, ATG appears to be safe and reasonable for HCV+ recipients.


Assuntos
Soro Antilinfocitário/administração & dosagem , Rejeição de Enxerto/epidemiologia , Hepatite C/tratamento farmacológico , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Condicionamento Pré-Transplante/métodos , Adulto , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Sobrevivência de Enxerto/imunologia , Hepacivirus/efeitos dos fármacos , Hepacivirus/imunologia , Hepacivirus/isolamento & purificação , Hepatite C/complicações , Hepatite C/diagnóstico , Hepatite C/imunologia , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Receptores de Interleucina-2/antagonistas & inibidores , Receptores de Interleucina-2/imunologia , Sistema de Registros/estatística & dados numéricos , Análise de Sobrevida , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia
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