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1.
Transplantation ; 104(8): 1703-1711, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732850

RESUMO

BACKGROUND: There are limited data on the outcome of transplant recipients with familial Mediterranean fever (FMF)-associated AA amyloidosis. The aim of the present study is to evaluate demographic, clinical, laboratory, and prognostic characteristics and outcome measures of these patients. METHODS: Eighty-one renal transplant recipients with FMF-associated AA amyloidosis (group 1) and propensity score-matched transplant recipients (group 2, n = 81) with nonamyloidosis etiologies were evaluated in this retrospective, multicenter study. Recurrence of AA amyloidosis was diagnosed in 21 patients (group 1a), and their features were compared with 21 propensity score-matched recipients with FMF amyloidosis with no laboratory signs of recurrence (group 1b). RESULTS: The risk of overall allograft loss was higher in group 1 compared with group 2 (25 [30.9%] versus 12 [14.8%]; P = 0.015 [hazard ratio, 2.083; 95% confidence interval, 1.126-3.856]). Patients in group 1 were characterized by an increased risk of mortality compared with group 2 (11 [13.6%] versus 0%; P = 0.001 [hazard ratio, 1.136; 95% confidence interval, 1.058-1.207]). Kaplan-Meier analysis revealed that 5- and 10-year patient survival rates in group 1 (92.5% and 70.4%) were significantly lower than in group 2 (100% and 100%; P = 0.026 and P = 0.023, respectively). Although not reaching significance, overall, 5- and 10-year graft survival rates (57.1%, 94.7%, and 53.8%, respectively) in group 1a were worse than in group 1b (76.2%, 95%, and 77.8%, respectively; P = 0.19, P = 0.95, and P = 0.27, respectively). CONCLUSIONS: AA amyloidosis is associated with higher risk of mortality after kidney transplantation. Inflammatory indicators should be monitored closely, and persistent high levels of acute-phase reactants should raise concerns about amyloid recurrence in allograft.


Assuntos
Amiloidose/cirurgia , Febre Familiar do Mediterrâneo/complicações , Rejeição de Enxerto/mortalidade , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Adulto , Aloenxertos/imunologia , Aloenxertos/patologia , Amiloidose/imunologia , Amiloidose/mortalidade , Amiloidose/patologia , Biópsia , Febre Familiar do Mediterrâneo/imunologia , Febre Familiar do Mediterrâneo/mortalidade , Febre Familiar do Mediterrâneo/cirurgia , Feminino , Seguimentos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto/imunologia , Humanos , Estimativa de Kaplan-Meier , Rim/imunologia , Rim/patologia , Falência Renal Crônica/imunologia , Falência Renal Crônica/mortalidade , Falência Renal Crônica/patologia , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Proteína Amiloide A Sérica/imunologia , Proteína Amiloide A Sérica/metabolismo , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
2.
PLoS One ; 15(7): e0235680, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32702005

RESUMO

AIMS: The European Senior Program (ESP) aims to avoid waiting list competition between younger and elderly patients applying for renal transplantation. By listing patients ≥65 years on a separate waiting list and locally allocating of grafts ≥65 years exclusively to this cohort, waiting and cold ischemia times are predicted to be shortened, potentially resulting in improved kidney transplantation outcomes. This study compared a historic cohort of renal transplant recipients being simultaneously listed on the general and the ESP waiting lists with a collective exclusively listed on the ESP list in terms of surrogates of the transplantation outcome. METHODS: Total 151 eligible patients ≥ 65 years from Münster transplant Center, Germany, between 1999 and 2014 were included. Graft function, graft and patient survival were compared using surrogate markers of short- and long-term graft function. Patients were grouped according to their time of transplantation. RESULTS: Recipients and donors in the newESP (nESP) cohort were significantly older (69.6 ± 3.5 years vs 67.1 ± 2 years, p<0.05; 72.0 ± 5.0 years vs 70.3 ± 5.0 years, p = 0.039), had significantly shorter dialysis vintage (19.6 ± 21.7 months vs 60.2 ± 28.1 months, p<0.001) and suffered from significantly more comorbidities (2.2 ± 0.9 vs 1.8 ± 0.8, p = 0.009) than the historic cohort (HC). Five-year death-censored graft survival was better than in the HC, but 5-year graft and patient survival were better in the ESP cohort. After 2005, cold ischemia time between groups was comparable. nESP grafts showed more primary function and significantly better long-term graft function 18 months after transplantation and onwards. CONCLUSION: nESP recipients received significantly older grafts, but experienced significantly shorter time on dialysis. Cold ischemia times were comparable, but graft function in the nESP cohort was significantly better in the long term.


Assuntos
Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Transplante de Rim , Idoso , Idoso de 80 Anos ou mais , Isquemia Fria/métodos , Comorbidade , Creatinina/sangue , Taxa de Filtração Glomerular , Rejeição de Enxerto/mortalidade , Humanos , Estimativa de Kaplan-Meier , Rim/fisiologia , Masculino , Modelos de Riscos Proporcionais , Diálise Renal , Estudos Retrospectivos , Doadores de Tecidos , Transplante Homólogo
3.
Pediatr Blood Cancer ; 67(9): e28483, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32568454

RESUMO

BACKGROUND: The role of splenectomy prior to hematopoietic stem cell transplantation (HSCT) is controversial. Only few studies compared the outcomes of splenectomized and nonsplenectomized children with transfusion-dependent thalassemia (TDT) undergoing allogeneic HSCTs. METHODS: A retrospective analysis was undertaken on a transplantation cohort of TDT patients; August 1987-December 2014 to compare transplant outcomes between splenectomized and nonsplenectomized groups. RESULTS: Ninety-six transplants in 86 TDT patients were analyzed. Sixteen patients were splenectomized before HSCTs. The splenectomized patients were significantly older (8.0 ± 1.9 vs 4.7 ± 0.6 years; P = 0.001), had larger livers and spleens (P = 0.001), and had a significantly shorter neutrophil engraftment time (absolute neutrophil count > 500/mm3 ; 15.0 ± 2.3 vs 19.2 ± 1.3 days; P = 0.004). Graft rejection occurred in 13.8% of the nonsplenectomized group, but not among the splenectomized patients. Though the splenectomized group's mortality rate was higher (25.0% vs 8.8%), this was not statistically significant (P = 0.491). The main causes of death in both groups were severe infections. The five-year overall survival (OS) rate was better for the nonsplenectomized group (91.78% vs 75.00%; P = 0.06). CONCLUSIONS: Although splenectomies prior to HSCT for the TDT patients in our cohort were associated with faster neutrophil engraftments and lower rejection rates, they did not produce significantly better OS or affect the mortality. As the splenectomies did not provide any distinct advantages, this procedure should not be routinely performed as a pre-HSCT regimen for TDT patients with splenomegaly. Better pre-HSCT preparation for TDT patients, including early and adequate blood transfusions to avoid splenomegaly, is recommended.


Assuntos
Rejeição de Enxerto/mortalidade , Transplante de Células-Tronco Hematopoéticas , Sistema de Registros , Esplenectomia , Talassemia/mortalidade , Talassemia/terapia , Adolescente , Aloenxertos , Transfusão de Sangue , Criança , Pré-Escolar , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Lactente , Masculino , Estudos Retrospectivos , Taxa de Sobrevida
4.
Biol Blood Marrow Transplant ; 26(7): e161-e166, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32389803

RESUMO

With the COVID-19 pandemic and the ensuing barriers to the collection and transport of donor cells, it is often necessary to collect and cryopreserve grafts before initiation of transplantation conditioning. The effect on transplantation outcomes in nonmalignant disease is unknown. This analysis examined the effect of cryopreservation of related and unrelated donor grafts for transplantation for severe aplastic anemia in the United States during 2013 to 2019. Included are 52 recipients of cryopreserved grafts who were matched for age, donor type, and graft type to 194 recipients who received noncryopreserved grafts. Marginal Cox regression models were built to study the effect of cryopreservation and other risk factors associated with outcomes. We recorded higher 1-year rates of graft failure (hazard ratio [HR], 2.26; 95% confidence interval, 1.17 to 4.35; P = .01) and of 1-year overall mortality (HR, 3.13; 95% CI, 1.60 to 6.11; P = .0008) after transplantation of cryopreserved compared with noncryopreserved grafts, with adjustment for sex, performance score, comorbidity, cytomegalovirus serostatus, and ABO blood group match. The incidence of acute and chronic graft-versus-host disease did not differ between the 2 groups. Adjusted probabilities of 1-year survival were 73% (95% CI, 60% to 84%) in the cryopreserved graft group and 91% (95% CI, 86% to 94%) in the noncryopreserved graft group. These data support the use of noncryopreserved grafts whenever possible in patients with severe aplastic anemia.


Assuntos
Anemia Aplástica/terapia , Transplante de Medula Óssea/métodos , Infecções por Coronavirus/epidemiologia , Criopreservação/métodos , Rejeição de Enxerto/patologia , Doença Enxerto-Hospedeiro/patologia , Transplante de Células-Tronco de Sangue Periférico/métodos , Pneumonia Viral/epidemiologia , Doença Aguda , Adolescente , Adulto , Idoso , Anemia Aplástica/imunologia , Anemia Aplástica/mortalidade , Anemia Aplástica/patologia , Criança , Pré-Escolar , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/mortalidade , Doença Enxerto-Hospedeiro/imunologia , Doença Enxerto-Hospedeiro/mortalidade , Teste de Histocompatibilidade , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Irmãos , Análise de Sobrevida , Condicionamento Pré-Transplante/métodos , Estados Unidos/epidemiologia , Doadores não Relacionados
5.
Nephrol Dial Transplant ; 35(6): 1043-1051, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32459843

RESUMO

BACKGROUND: The objective of this study was to establish if renal transplant outcomes (graft and patient survival) for young adults in England were worse than for other age groups. METHODS: Outcomes for all renal transplant recipients in England (n = 26 874) were collected from Hospital Episode Statistics and the Office for National Statistics databases over 12 years. Graft and patient outcomes, follow-up and admissions were studied for all patients, stratified by age bands. RESULTS: Young adults (14-23 years) had substantially greater likelihood [hazard ratio (HR) = 1.26, 95% confidence interval (CI) 1.10-1.19; P < 0.001] of kidney transplant failure than any other age band. They had a higher non-attendance rate for clinic appointments (1.6 versus 1.2/year; P < 0.001) and more emergency admissions post-transplantation (25% of young adults on average are admitted each year, compared with 15-20% of 34- to 43-year olds). Taking into account deprivation, ethnicity, transplant type and transplant centre, in the 14- to 23-year group, return to dialysis remained significantly worse than all other age bands (HR = 1.41, 95% CI 1.26-1.57). For the whole cohort, increasing deprivation related to poorer outcomes and black ethnicity was associated with poorer outcomes. However, neither ethnicity nor deprivation was over-represented in the young adult cohort. CONCLUSIONS: Young adults who receive a kidney transplant have a significant increased likelihood of a return to dialysis in the first 10 years post-transplant when compared with those aged 34-43 years in multivariable analysis.


Assuntos
Rejeição de Enxerto/mortalidade , Falência Renal Crônica/mortalidade , Transplante de Rim/mortalidade , Sistema de Registros/estatística & dados numéricos , Transplantados/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Feminino , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
6.
Transplantation ; 104(4): 847-855, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32224814

RESUMO

BACKGROUND: Kidney transplant outcomes of indigenous Australians are poorer compared with nonindigenous Australians, but it is unknown whether the type of acute rejection differs between these patient groups or whether rejection mediates the effect between ethnicity, death-censored graft failure (DCGF), and death with a functioning graft (DWFG). METHODS: Biopsy-proven acute rejection (BPAR) rates and types were compared between indigenous and nonindigenous recipients. The associations between ethnicity, BPAR, DCGF, and DWFG were examined using adjusted competing risk analyses, and mediation analysis was conducted to determine whether BPAR mediated the adverse effects between ethnicity and outcomes. RESULTS: Fifty-seven (9.3%) of 616 patients who have received kidney-only transplants between 2000 and 2010 in Western Australia were indigenous. Compared with nonindigenous recipients, BPAR rates were higher in indigenous recipients (42 versus 74 episodes/100 recipients, P < 0.01), with an excess of antibody-mediated rejections. During a median follow-up of 8 years, indigenous recipients were more likely to experience BPAR, DCGF, and DWFG compared with nonindigenous recipients, with adjusted subdistribution hazard ratio of 1.94 (1.39-2.70), 1.53 (0.85-2.76; P = 0.159), and 2.14 (1.13-4.06; P = 0.020), respectively. Although 70% of the effect between ethnicity and DCGF was mediated by BPAR, no similar association was found for DWFG. CONCLUSIONS: Indigenous recipients experienced poorer allograft and patient outcomes compared with nonindigenous recipients, with BPAR an important determinant for DCGF. Future research identifying other risk factors and mediators associated with patient survival in indigenous recipients should be considered a priority.


Assuntos
Rejeição de Enxerto/etnologia , Disparidades nos Níveis de Saúde , Povos Indígenas , Falência Renal Crônica/cirurgia , Transplante de Rim , Grupo com Ancestrais Oceânicos , Doença Aguda , Adolescente , Adulto , Biópsia , Criança , Pré-Escolar , Assistência à Saúde Culturalmente Competente/etnologia , Feminino , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/tratamento farmacológico , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Humanos , Imunossupressores/uso terapêutico , Incidência , Lactente , Recém-Nascido , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/etnologia , Falência Renal Crônica/mortalidade , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Austrália Ocidental/epidemiologia , Adulto Jovem
7.
Transplantation ; 104(4): 881-887, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32224815

RESUMO

BACKGROUND: Tacrolimus (TAC) is the most important agent for maintenance immunosuppression and prevention of immunologic injury to the renal allograft, yet there remains no consensus on how best to monitor drug therapy. Both high TAC intrapatient variability and low TAC time in therapeutic range (TTR) have been associated with risk of de novo donor-specific antibodies (dnDSA). In this study, we hypothesized that the risk associated with high TAC coefficient of variation (CV) is a result of low TAC TTR rather than the variability itself. METHODS: We analyzed the risk of dnDSA, acute rejection, or death-censored graft loss by non-dosed-corrected TAC CV and TAC TTR during the first posttransplant year in a cohort of 538 patients with a median follow-up period of 4.1 years. RESULTS: Patients with CV >44.2% and TTR <40% (high intrapatient variability and low TTR) had a high risk of dnDSA (adjusted OR = 4.93, 95% confidence interval = 2.02-12.06, P < 0.001) and death-censored graft loss by 5 years (adjusted HR = 4.00, 95% confidence interval = 1.31-12.24, P = 0.015) when compared with patients with CV >44.2% and TTR ≥40% (high intrapatient variability and optimal TTR), while the latter patients had similar risk to patients with CV <44.2% (lower intrapatient variability). CONCLUSIONS: These data suggest that previously reported immunologic risk associated with high TAC intrapatient variability is due to time outside of therapeutic range rather than variability in and of itself when evaluating absolute non-dose-corrected TAC levels irrespective of reason or indication.


Assuntos
Inibidores de Calcineurina/uso terapêutico , Monitoramento de Medicamentos , Rejeição de Enxerto/prevenção & controle , Antígenos HLA/imunologia , Imunossupressores/uso terapêutico , Isoanticorpos/sangue , Transplante de Rim , Tacrolimo/uso terapêutico , Adulto , Biomarcadores/sangue , Inibidores de Calcineurina/efeitos adversos , Inibidores de Calcineurina/sangue , Feminino , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto/efeitos dos fármacos , Humanos , Imunossupressores/efeitos adversos , Imunossupressores/sangue , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tacrolimo/efeitos adversos , Tacrolimo/sangue , Fatores de Tempo , Resultado do Tratamento
8.
Am J Cardiol ; 125(10): 1517-1523, 2020 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-32238278

RESUMO

Hypomagnesemia is commonly observed in heart transplant (HT) recipients receiving calcineurin inhibitors. Since low serum magnesium (s-Mg) has been implicated in the progression of atherosclerosis, potentially leading to worsening coronary heart disease, arrhythmias and sudden death, we investigated the association between s-Mg and HT outcomes. Between 2002 and 2017, 150 HT patients assessed for s-Mg were divided into high (≥1.7 mg/dL) and low s-Mg groups according to the median value of all s-Mg levels recorded during the first 3 months post-HT. Endpoints included survival, cardiac allograft vasculopathy (CAV), any-treated rejection (ATR) and NF-MACE. Kaplan-Meier analysis showed that at 15 years after HT, both survival (76 vs 33%, log-rank p = 0.007) and freedom from CAV (75 vs 48%, log-rank p = 0.01) were higher in the high versus low s-Mg group. There were no significant differences in freedom from NF-MACE or ATR. Multivariate analyses consistently demonstrated that low s-Mg was independently associated with a significant 2.6-fold increased risk of mortality and 4-fold increased risk of CAV (95%CI 1.06 to 6.4, p = 0.04; 95%CI 1.12 to 14.42, p = 0.01, respectively). In conclusion, low s-Mg is independently associated with increased mortality and CAV in HT patients. Larger multi-center prospective studies are needed to confirm these findings and to examine the effect of Mg supplementation.


Assuntos
Cardiopatias/mortalidade , Transplante de Coração/mortalidade , Hipercalciúria/complicações , Nefrocalcinose/complicações , Complicações Pós-Operatórias/mortalidade , Erros Inatos do Transporte Tubular Renal/complicações , Feminino , Rejeição de Enxerto/mortalidade , Cardiopatias/etiologia , Humanos , Magnésio/sangue , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
9.
Transplant Proc ; 52(4): 1140-1142, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32220481

RESUMO

BACKGROUND: Pretransplant anti-HLA antibodies are a risk factor for graft rejection and loss, and its percentage estimate is known as panel-reactive antibody (PRA). Our objective was to evaluate the influence of PRA on the survival of renal grafts from living donors over a period of 10 years. METHODS: Retrospective analysis was completed in all living donor transplants with PRA class I and class II from October 2008 to December 2018 with follow-up until June 2019. The methods used for the PRA were flow cytometry and Luminex. Graft survival (not censored) was evaluated by Kaplan-Meier (log-rank) and Cox regression. P < .05 was considered significant. RESULTS: The study included 393 patients. PRA class I mean was 9.8 ± 20% (0%-98%) and class II mean was 8.6 ± 17.8% (0%-97.8%). Of the patients, 81.9% had a PRA <20% for any class. Uncensored graft survival at 1, 5, and 10 years was 90.3%, 76.2%, and 69.3%, respectively. Mean estimated uncensored graft survival in PRA <20% patients (103.9 ± 2.7, 95% confidence interval [CI] 96.6-11.2) was higher than that of PRA >20% patients (61.5 ± 5.7, 95% CI 50.3-72.8) (P = .005 log-rank). Cox regression (univariate) was statistically significant for PRA class I (Exp [B] 1.01, 95% CI 1.003-1.02, P = .009) and for PRA >20% any class (Exp [B] 2.074, 95% CI 1.222-3.520, P = .007). CONCLUSION: PRA class I and PRA >20% any class are associated with lower graft survival. PRA must be considered to determine immunologic risk and to choose an immunosuppressive regimen in kidney transplantation.


Assuntos
Rejeição de Enxerto/imunologia , Sobrevivência de Enxerto/imunologia , Isoanticorpos/imunologia , Transplante de Rim , Adolescente , Adulto , Idoso , Feminino , Rejeição de Enxerto/mortalidade , Humanos , Isoanticorpos/sangue , Transplante de Rim/mortalidade , Doadores Vivos , Masculino , México , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplantes/imunologia , Adulto Jovem
10.
Scand Cardiovasc J ; 54(3): 192-199, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32148103

RESUMO

Objectives. Lung transplantation remains the only available treatment option for many end-stage lung diseases. We evaluated our long-term lung transplantation results and the impact of chronic lung allograft dysfunction (CLAD). Design. Adult de novo lung transplants (2003-2015, n=175) in a nationwide single transplant center were retrospectively analyzed. Kaplan-Meier survival and Cox regression analysis were used to evaluate the effect of CLAD. Results. Recipient and graft 1-, 5- and 10-year survival estimates were 94%, 79% and 64%, and 93%, 75% and 59%, respectively. CLAD affected 43% of patients at a median of 2.3 years after transplantation, and impaired recipient (p = .03) and graft survival (p = .001) with the most advanced CLAD stage, and restrictive CLAD phenotype, resulting in worst graft survival. CLAD was the primary cause of death in 54% of all patients, and in 80% of patients with an established CLAD diagnosis. CLAD, high-risk cytomegalovirus serostatus, and recipient preoperative sensitization increased graft loss hazard ratio. CLAD was the only significant investigated risk factor for graft loss in multivariate regression analysis. Conclusions. Although very favourable lung transplant patient long-term survival was achieved, CLAD significantly impaired recipient and graft survival. Identification of risk factors and therapeutic options for CLAD may further improve lung transplantation results.


Assuntos
Bronquiolite Obliterante/epidemiologia , Rejeição de Enxerto/epidemiologia , Sobrevivência de Enxerto , Transplante de Pulmão/efeitos adversos , Adulto , Idoso , Bronquiolite Obliterante/diagnóstico , Bronquiolite Obliterante/mortalidade , Doença Crônica , Feminino , Finlândia/epidemiologia , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/mortalidade , Humanos , Incidência , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
11.
PLoS One ; 15(2): e0228096, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32023273

RESUMO

BACKGROUND: The hypothesis was tested that parameters of an aged T-cell compartment associate with the risk for late rejection after kidney transplantation. METHODS: Recipients of a kidney transplant in the period 2007-2013 were (N = 365) were included. T cells were characterized prior to transplantation by flow cytometry as naive (CD45RO-CCR7+), central-memory (CD45RO+CCR7+), effector-memory (CD45RO-CCR7-) or terminally differentiated CD8+ Temra (CD45RO-/CCR7-/CD28-) cells. T cell telomere length and thymic output were assessed prior to transplantation in 202 recipients. Follow-up was until December 2018. The date of the first time of biopsy-proven late rejection (>6 months after transplantation) was used to calculate the rejection-free survival time. RESULTS: Fifty cases of biopsy-proven rejection were recorded. Thymic output and T cell telomere length did not associate with late rejection-free survival. However, the percentage and absolute numbers of CD8+Temra and CD28null CD8+ T cells were significantly lower in patients with late rejection. Specifically, in the highest tertile of percentages of CD28null CD8+ T cells, the cumulative incidence of late rejection at 5 and 10 years was only 5% and 8% compared to 16% and 20% in the middle to lowest tertile (p = 0.002). Multivariate proportional hazard analysis showed that percentage and absolute number of CD28null CD8+ T cells remained significantly associated with late rejection and rejection-related graft loss. CONCLUSION: High numbers of differentiated CD28null CD8+ T cells decrease the risk for late rejection and rejection-related graft loss after kidney transplantation.


Assuntos
Antígenos CD28/metabolismo , Linfócitos T CD8-Positivos/metabolismo , Rejeição de Enxerto/patologia , Transplante de Rim , Adolescente , Adulto , Idoso , Linfócitos T CD4-Positivos/citologia , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD4-Positivos/metabolismo , Linfócitos T CD8-Positivos/citologia , Linfócitos T CD8-Positivos/imunologia , Diferenciação Celular , Feminino , Seguimentos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/mortalidade , Humanos , Estimativa de Kaplan-Meier , Rim/imunologia , Rim/patologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Risco , Transplante Homólogo , Adulto Jovem
12.
J Thorac Cardiovasc Surg ; 160(2): 572-581, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31924361

RESUMO

OBJECTIVES: To study the impact of using the US Public Health Service broadened definition of "increased-risk" donors (2013) in comparison with "high-risk" (1994) and standard infectious risk donors on lung transplant recipient outcomes. METHODS: Patients who underwent lung transplant between January 1, 2006, and May 31, 2017, in the Scientific Registry of Transplant Recipients were divided into 2 cohorts, recipients of: (1) high-risk donors: January 1, 2006, to October 1, 2013, and (2) increased-risk donors: January 1, 2014, to May 31, 2017, and compared with matched recipients who received standard-risk donors. Risks for acute rejection, patient, and graft survival using propensity score matched cohorts, multivariable logistic, and Cox models were examined. RESULTS: In total, 18,490 lung transplant recipients were analyzed with 36% transplanted during the increased-risk donor definition period. The proportion of donors classified as nonstandard infectious risk increased with the definition change (8% high-risk donors vs 22% increased-risk donors; P < .001). In both cohorts, male patients with a lower forced expiratory volume in 1 second and greater creatinine were more likely to receive an organ from increased risk donors. Neither graft nor patient survival differed by donor type in either period. Acute treated rejection within 1 year did not differ by period for recipients of increased risk donors (odds ratio, 0.87; P = .23) or recipients of high-risk donors (odds ratio, 1.2; P = .27). CONCLUSIONS: The 2013 broadened definition of donor risk increased the proportion of nonstandard infectious risk donors. Recipients of increased/high-risk donors had similar graft and patient survival compared with standard-risk donors.


Assuntos
Seleção do Doador , Pneumopatias/cirurgia , Transplante de Pulmão/efeitos adversos , Terminologia como Assunto , Doadores de Tecidos/classificação , Adulto , Idoso , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Nível de Saúde , Humanos , Incidência , Pneumopatias/diagnóstico , Pneumopatias/mortalidade , Pneumopatias/fisiopatologia , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Public Health Service , Adulto Jovem
13.
Transplantation ; 104(4): 754-761, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31568214

RESUMO

BACKGROUND: Liver transplantation is the most suitable treatment option available for end-stage liver disease. However, some patients require retransplantation, despite medical advances that have led to improved survival. We aimed to compile a definitive, nationwide resource of liver retransplantation data in Japan, seeking to identify the predictors of patient survival posttransplantation. METHODS: Questionnaires were sent to 32 institutions that had conducted 281 retransplantations before 2015. RESULTS: Among the 265 patients included in this study (142 pediatric cases), the average age at primary transplantation was 23 years, and retransplantation was performed after an average of 1468 days. The main indication for retransplantation was graft rejection (95 patients). Living-donor liver transplantation accounted for 94.7% of primary transplantations and 73.2% of retransplantations. Patient survival at 1, 3, or 5 years did not differ by type of transplantation but was better for pediatric (70.8%, 68.3%, and 60.1%, respectively) than for adult (57.2%, 50.4%, and 45.2%, respectively) recipients (P = 0.0003). Small-for-size syndrome, retransplantation within 365 days, and inpatient status at retransplantation were significant predictors of poor survival in pediatric cases. Retransplantation within 365 days and conditions warranting retransplantation were significant predictors of poor survival in adult patients. CONCLUSIONS: In Japan, where >70% of retransplantations are performed using living donors, the indications and timing are different from those in previous reports from other countries, while maintaining comparable survival rates. Considering technical challenges, graft failure within 365 days should be thoroughly restricted to justify the use of living donor.


Assuntos
Rejeição de Enxerto/cirurgia , Hepatopatias/cirurgia , Transplante de Fígado , Doadores Vivos , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Seleção do Doador , Feminino , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Pesquisas sobre Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Japão , Hepatopatias/diagnóstico , Hepatopatias/mortalidade , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
14.
Transplantation ; 104(7): 1403-1412, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31651789

RESUMO

BACKGROUND: Chronic renal disease (CKD) jeopardizes the long-term outcomes of liver transplant recipients. In patients with end-stage liver graft disease and CKD, liver retransplantation associated with kidney transplantation (ReLT-KT) might be necessary. Yet, this specific subset of patients remains poorly described. METHODS: Indications, perioperative characteristics, and short- and long-term outcomes of patients undergoing ReLT-KT at 2 transplantation units from 1994 to 2012 were analyzed. Risk factors for postoperative mortality and long-term survivals were evaluated. RESULTS: Among 3060 patients undergoing liver transplantation (LT), 45 (1.5%) underwent ReLT-KT. The proportion of ReLT-KT among LT recipients continuously grew throughout the study period from 0.3% to 2.4% (P < 0.001). Median time from primary LT to ReLT-KT was 151.3 (7.5-282.9) months. The most frequent indications for liver retransplantation were recurrence of the primary liver disease and cholangitis in 15 (33.3%) cases each. CKD was related to calcineurin inhibitors toxicity in 38 (84.4%) cases. Twelve (26.7%) patients died postoperatively. D-MELD (donor age × recipients' MELD) was associated with postoperative mortality (HR: 8.027; 95% CI: 2.387-18.223; P = 0.026) and optimal cut-off value was 1039 (AUC: 0.801; P = 0.002). Overall 1, 3, and 5 years survivals were 68.8%, 65.9%, and 59.5%, respectively. D-MELD > 1039 was the only factor associated with poor survival (P = 0.021). CONCLUSIONS: ReLT-KT is a highly morbid increasingly performed procedure. Refinements in the selection of grafts and transplant candidates are required to limit the postoperative mortality of these patients.


Assuntos
Doença Hepática Terminal/cirurgia , Rejeição de Enxerto/cirurgia , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Aloenxertos/patologia , Aloenxertos/transplante , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Rejeição de Enxerto/complicações , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/etiologia , Falência Renal Crônica/mortalidade , Transplante de Rim/métodos , Transplante de Rim/estatística & dados numéricos , Fígado/patologia , Fígado/cirurgia , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Recidiva , Reoperação/efeitos adversos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Resultado do Tratamento , Adulto Jovem
15.
Nephrol Dial Transplant ; 35(5): 888-894, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30165691

RESUMO

BACKGROUND: Whether calcium oxalate (CaOx) deposition in kidney allografts following transplantation (Tx) adversely affects patient outcomes is uncertain, as are its associated risk factors. METHODS: We performed a retrospective cohort study of patients who had kidney allograft biopsies performed within 3 months of Tx at Brigham and Women's Hospital and examined the association of CaOx deposition with the composite outcome of death or graft failure within 5 years. RESULTS: Biopsies from 67 of 346 patients (19.4%) had CaOx deposition. In a multivariable logistic regression model, higher serum creatinine [odds ratio (OR) = 1.28 per mg/dL, 95% confidence interval (CI) 1.15-1.43], longer time on dialysis (OR = 1.11 per additional year, 95% CI 1.01-1.23) and diabetes (OR = 2.26, 95% CI 1.09-4.66) were found to be independently associated with CaOx deposition. CaOx deposition was strongly associated with delayed graft function (DGF; OR = 11.31, 95% CI 5.97-21.40), and with increased hazard of the composite outcome after adjusting for black recipient race, donor type, time on dialysis before Tx, diabetes and borderline or acute rejection (hazard ratio 1.90, 95% CI 1.13-3.20). CONCLUSIONS: CaOx deposition is common in allografts with poor function and portends worse outcomes up to 5 years after Tx. The extent to which CaOx deposition may contribute to versus result from DGF, however, cannot be determined based on our retrospective and observational data. Future studies should examine whether reducing plasma and urine oxalate prevents CaOx deposition in the newly transplanted kidney and whether this has an effect on clinical outcomes.


Assuntos
Oxalato de Cálcio/metabolismo , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Nefropatias/mortalidade , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Aloenxertos , Feminino , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/metabolismo , Humanos , Nefropatias/metabolismo , Nefropatias/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
16.
Nephrol Dial Transplant ; 35(3): 534-543, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203080

RESUMO

BACKGROUND: Updated survival outcomes of young recipients receiving young or old deceased donor kidneys are required when considering accepting a deceased donor kidney. METHODS: We examined outcomes in 6448 European kidney allografts donated from younger (≥20-<50 years) and older (≥50-<70 years) deceased donors when transplanted into very young (≥20-<35 years) or young (≥35-<50 years) adult recipients. Outcomes of first kidney transplantations during 2000-13 and followed-up to 2015 were determined via competing risk, restricted mean survival and Cox regression methods. RESULTS: The 10-year cumulative incidence of graft failure was lowest in very young {22.0% [95% confidence interval (95% CI) 19.1-24.9]} and young [15.3% (95% CI 13.7-16.9)] recipients of younger donor kidneys and highest in very young [36.7% (95% CI 31.9-41.5)] and young [29.2% (95% CI 25.1-33.2)] recipients of older donor kidneys. At the 10-year follow-up, younger donor kidneys had a 1 year (very young) or 9 months (young) longer mean graft survival time compared with older donor kidneys. Graft failure risk in younger donor kidneys was 45% [very young adjusted hazard ratio (aHR) 0.55 (95% CI 0.44-0.68)] and 40% [young aHR 0.60 (95% CI 0.53-0.67)] lower compared with older donor kidneys. A 1-year increase in donor age resulted in a 2% [very young aHR 1.02 (95% CI 1.00-1.04)] or 1% [young aHR 1.01 (95% CI 1.00-1.01)] increase in the 10-year risk of death. CONCLUSIONS: Younger donor kidneys show survival benefits over older donor kidneys in adult recipients ages 20-50 years. Updated survival outcomes from older deceased donors are necessary due to advances in transplantation medicine and the increasing role these donors play in organ transplantation.


Assuntos
Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Transplante de Rim/mortalidade , Sistema de Registros/estatística & dados numéricos , Doadores de Tecidos/provisão & distribução , Adulto , Idoso , Morte , Europa (Continente)/epidemiologia , Feminino , Rejeição de Enxerto/epidemiologia , Humanos , Incidência , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Prognóstico , Taxa de Sobrevida , Doadores de Tecidos/estatística & dados numéricos , Transplantados , Adulto Jovem
17.
Nephrol Dial Transplant ; 35(7): 1262-1270, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-31411724

RESUMO

BACKGROUND: Disability in general has been associated with poor outcomes in kidney transplant (KT) recipients. However, disability can be derived from various components, specifically visual, hearing, physical and walking impairments. Different impairments may compromise the patient through different mechanisms and might impact different aspects of KT outcomes. METHODS: In our prospective cohort study (June 2013-June 2017), 465 recipients reported hearing, visual, physical and walking impairments before KT. We used hybrid registry-augmented Cox regression, adjusting for confounders using the US KT population (Scientific Registry of Transplant Recipients, N = 66 891), to assess the independent association between impairments and post-KT outcomes [death-censored graft failure (DCGF) and mortality]. RESULTS: In our cohort of 465 recipients, 31.6% reported one or more impairments (hearing 9.3%, visual 16.6%, physical 9.1%, walking 12.1%). Visual impairment was associated with a 3.36-fold [95% confidence interval (CI) 1.17-9.65] higher DCGF risk, however, hearing [2.77 (95% CI 0.78-9.82)], physical [0.67 (95% CI 0.08-3.35)] and walking [0.50 (95% CI 0.06-3.89)] impairments were not. Walking impairment was associated with a 3.13-fold (95% CI 1.32-7.48) higher mortality risk, however, visual [1.20 (95% CI 0.48-2.98)], hearing [1.01 (95% CI 0.29-3.47)] and physical [1.16 (95% CI 0.34-3.94)] impairments were not. CONCLUSIONS: Impairments are common among KT recipients, yet only visual impairment and walking impairment are associated with adverse post-KT outcomes. Referring nephrologists and KT centers should identify recipients with visual and walking impairments who might benefit from targeted interventions pre-KT, additional supportive care and close post-KT monitoring.


Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Rejeição de Enxerto/mortalidade , Perda Auditiva/fisiopatologia , Falência Renal Crônica/mortalidade , Transplante de Rim/mortalidade , Limitação da Mobilidade , Transtornos da Visão/fisiopatologia , Adulto , Feminino , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Humanos , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Atividade Motora , Prognóstico , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Taxa de Sobrevida , Transplantados , Caminhada
18.
Transplantation ; 104(4): 823-834, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31369517

RESUMO

BACKGROUND: The negative role of HLA class II donor-specific antibody on graft outcome is well recognized. However, the potentially negative cardiovascular effects of preformed HLA class II antibodies and donor HLA in kidney transplant recipients (KTRs) remain unestablished. METHODS: We conducted a single-center, retrospective cohort study including 1115 KTRs (2003-2016) with up to 4449 person-years of follow-up after transplantation and a median follow-up time of 5.1 years (interquartile range, 2.7-7.6). We evaluated the unadjusted and multivariable-adjusted association between pretransplant HLA class I and II antibodies, as well as HLA-DR1 donor/recipient genotype and the primary (major adverse cardiac and cerebrovascular event [MACCE] or all-cause mortality) and secondary (MACCE or cardiovascular mortality) outcome. RESULTS: In a multivariate Cox proportional hazard model, HLA class II antibodies before transplantation were associated with increased adjusted hazard ratio (aHR) for MACCE or all-cause mortality (aHR, 1.71 [1.13-2.60]; P = 0.012) even after adjustment for time-varying covariate graft loss (aHR, 1.68 [1.08-2.62]; P = 0.022) and biopsy-proven acute rejection (aHR, 1.71 [1.13-2.60]; P = 0.012). HLA class II antibodies were also associated with increased aHR for the secondary outcome, MACCE, or cardiovascular mortality (aHR, 1.92 [1.12-3.30]; P = 0.018). We investigated the effect of donor and recipient HLA-DR1 on these outcome parameters and demonstrated that KTRs with HLA-DR1 positive donors had an increased aHR for MACCE with all-cause (aHR, 1.45 [1.09-1.94]; P = 0.012) and cardiovascular mortality (aHR, 1.49 [1.00-2.22]; P = 0.05). CONCLUSIONS: Prior sensitization against HLA class II antigens is associated with unfavorable long-term cardiovascular outcome in KTRs independent of graft loss or rejection. Recipients of an HLA-DR1 donor also have an impaired cardiovascular outcome.


Assuntos
Doenças Cardiovasculares/imunologia , Antígenos HLA/imunologia , Histocompatibilidade , Isoanticorpos/sangue , Transplante de Rim/efeitos adversos , Adulto , Biomarcadores/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Causas de Morte , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/mortalidade , Sobrevivência de Enxerto , Antígenos HLA/classificação , Antígeno HLA-DR1/imunologia , Humanos , Isoanticorpos/classificação , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Nephrol Dial Transplant ; 35(4): 706-714, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30753729

RESUMO

BACKGROUND: Kidney transplant recipients (KTRs) experience substantial survival benefit compared with dialysis patients. However, their mortality and graft failure risk remain high. KTRs are often low in micronutrient status, including vitamins D and K. We investigated the association of both vitamins D and K status, and vitamin D treatment with all-cause mortality and death-censored graft failure. METHODS: We studied 461 KTRs from a single-centre study at median 6.1 years after transplantation. At baseline, vitamins D and K concentrations were measured by 25-hydroxyvitamin D [25(OH)D] and dephosphorylated uncarboxylated matrix gla protein (dp-ucMGP) and patients were categorized into: 25(OH)D <50/≥50 nmol/L and median dp-ucMGP <1057/≥1057 pmol/L. RESULTS: Mean age was 52 ± 12 years, and 122 KTRs (26%) had low vitamins D and K status. During median 9.8 years follow-up, 128 patients (28%) died and 48 (10%) developed death-censored graft failure. Low vitamins D and K status was associated with 2.33 (1.26-4.30) [hazard ratio (95% confidence interval)] increased mortality risk and 3.25 (1.17-9.08) increased graft failure risk compared with KTR with 25(OH)D ≥50 nmol/L and dp-ucMGP <1057 pmol/L. Dp-ucMGP was strongly associated with mortality (per 500 pmol/L increase): 1.41 (1.08-1.41) for vitamin D treatment versus no treatment 1.07 (0.97-1.18), and graft failure 1.71 (1.17-2.49) for vitamin D treatment versus 1.19 (1.05-1.36) no treatment, P-interaction <0.07 for vitamin D treatment (n = 44). CONCLUSIONS: Combined vitamins D and K deficiency are highly prevalent and are associated with increased mortality and graft failure risk compared with high vitamins D and K status. Low vitamin K status was strongly associated with an increased risk of premature mortality and graft failure for patients treated with vitamin D versus no vitamin D treatment.


Assuntos
Rejeição de Enxerto/mortalidade , Nefropatias/mortalidade , Transplante de Rim/efeitos adversos , Complicações Pós-Operatórias/mortalidade , Vitamina D/sangue , Deficiência de Vitamina K/complicações , Vitamina K/sangue , Feminino , Rejeição de Enxerto/sangue , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto , Humanos , Nefropatias/sangue , Nefropatias/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida
20.
Clin Transplant ; 33(12): e13752, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31693247

RESUMO

BACKGROUND: Continuous-flow mechanical circulatory support (CF-MCS) is associated with impaired vascular function and increased risk of vasoplegia. One contributing factor to early graft failure (EGF) is severe vasoplegia. We tested the hypothesis that CF-MCS is associated with increased risk of EGF. METHODS: Adult primary heart transplant recipients in the ISHLT Registry from 2005 to 2013 were stratified into three groups based on pre-transplant MCS: No MCS (n = 11 748), pulsatile (P)-MCS (n = 718), and CF-MCS (n = 3818). EGF was defined as death/retransplantation due to graft failure within 30 days after HT. Comparisons were made using descriptive statistics and associations. EGF was assessed with multivariable Cox proportional hazard regression. RESULTS: The incidence of EGF within 30 days was similar between groups (No MCS 2.2%, P-MCS 3.3%, CF-MCS 2.1%, P = .10). Following multivariable adjustment, the risk of EGF was not statistically different for those with CF-MCS compared with P-MCS (HR 0.75, 95% CI 0.46-1.21, P = .24). The risk of EGF was numerically, but not statistically significantly higher for CF-MCS compared with No MCS (HR 1.24, 95% CI 0.92-1.67, P = .16). CONCLUSION: CF-MCS use was not associated with a statistically significant increased risk of EGF resulting in death or retransplantation in the first 30 days after transplant.


Assuntos
Circulação Extracorpórea/métodos , Rejeição de Enxerto/mortalidade , Insuficiência Cardíaca/mortalidade , Transplante de Coração/mortalidade , Coração Auxiliar/estatística & dados numéricos , Transplante de Pulmão/mortalidade , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/terapia , Sobrevivência de Enxerto , Insuficiência Cardíaca/cirurgia , Transplante de Coração/efeitos adversos , Humanos , Transplante de Pulmão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
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