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1.
Autops. Case Rep ; 9(4): e2019112, Oct.-Dec. 2019. ilus, tab
Artigo em Inglês | LILACS | ID: biblio-1024207

RESUMO

Renal transplant patients are treated with immunosuppressive drugs that decrease the effectiveness of the immune system, making them more prone to developing cancer. Skin and lip carcinomas are common malignancies encountered after transplantation, whereas oral carcinomas are rare. We report the case of a 51-year-old female Caucasian patient, with no history of smoking, who presented white lesions on the tongue and an ulcerated lesion on the lower lip beginning 4 months prior. Diagnosis of squamous cell carcinoma for both lesions was made following incisional biopsies. Interestingly, the patient reported a renal transplantation 23 years prior, and was maintained on a combination of cyclosporine, mycophenolate sodium and prednisone. The patient also presented a history of several basal and squamous cell carcinomas on sun-exposed areas of the skin. Both lesions were surgically excised. No sign of recurrence or new lesions in the oral cavity have been observed; however, new skin lesions are frequently diagnosed. This case report highlights that oral cancers may occur in transplant patients in the absence of classical risk factors. Thus, clinicians must be aware of the importance of thorough oral examination in transplant patients in routine follow-up.


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Neoplasias Bucais/etiologia , Neoplasias Bucais/patologia , Neoplasias Bucais/prevenção & controle , Carcinoma de Células Escamosas/patologia , Transplante de Rim/efeitos adversos , Imunossupressores/efeitos adversos
2.
Medicine (Baltimore) ; 98(45): e17878, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702658

RESUMO

RATIONALE: Donor-derived bacterial infection is a rare cause of morbidity after solid organ transplantation (SOT) but associated with significant morbidity and mortality, deaths caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) infection account for a considerable proportion of postoperation mortality rate in liver and kidney recipients. The arterial rupture as a result of fungal arteritis is occasionally described, while the rupture of graft vascular anastomosis after SOT due to donor-derived CRKP infection is rarely reported. PATIENTS CONCERNS: We reported 1 patient with donor-derived CRKP infection following liver transplantation and 2 patients following renal transplantation (1 liver and 2 kidneys were from the same donor), who experienced sudden abdominal pain and abdominal hemorrhage almost at the same time after organ transplantation. DIAGNOSIS: The patients were diagnosed as graft arteries rupture due to corrosion caused by CRKP infection based on computed tomography scan, blood culture, laparotomy, and pulse-field gel electrophoresis. INTERVENTIONS: Anti-shock treatment, exploratory laparotomy, broad-spectrum antibiotics, and abdominal puncture and drainage were given. OUTCOMES: The liver recipient survived as well as the liver graft, still under treatment of multiple abdominal infections. The 2 renal recipients were alive after resection of the renal grafts and underwent hemodialysis. LESSONS: Rupture of graft artery should be foreseen when donor-derived CRKP infection was confirmed and broad-spectrum antibiotics and other interventions need to be considered.


Assuntos
Transplante de Rim/efeitos adversos , Infecções por Klebsiella/etiologia , Transplante de Fígado/efeitos adversos , Adulto , Antibacterianos , Enterobacteriáceas Resistentes a Carbapenêmicos/isolamento & purificação , Feminino , Artéria Hepática/diagnóstico por imagem , Humanos , Infecções por Klebsiella/tratamento farmacológico , Klebsiella pneumoniae/isolamento & purificação , Masculino , Pessoa de Meia-Idade , Artéria Renal/diagnóstico por imagem , Ruptura/etiologia , Doadores de Tecidos
3.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 11(5): 1202-1207, out.-dez. 2019. tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1022269

RESUMO

Objetivo: Avaliar as características clínicas e imunológica dos receptores de transplante renal. Métodos: estudo documental e retrospectivo, realizado em um Ambulatório do Hospital Geral de Fortaleza, Fortaleza, Ceará, Brasil, com pacientes internados no período de junho de 2012 a junho de 2014. A amostra foi composta por 300 pacientes submetidos ao transplante renal. As variáveis preditoras de interesse, foram subdivididas em: características prétransplante, características pós-transplante e características imunológicas. Utilizou-se testes de Pearson e Spearman para avaliar correlação entre variáveis. Resultados: Houve predomínio de pacientes do sexo masculino (65%), com faixa etária entre 44 e 56 anos (31,4%). Demonstrou-se relação estatisticamente significante entre o DSA e a disfunção do enxerto (p<0,04), Rejeição celular o Painel Reativo classe I (p< 0,05), o tempo de internação e a disfunção do enxerto (p<0,001) e entre o entre o HLA e o MISMATCH. Conclusão: Aponta-se a necessidade de um acompanhamento crítico e individualizado do paciente transplantado por parte dos profissionais para garantir o sucesso do transplante a longo prazo


Objective: The study's purpose has been to assess both clinical and immunological characteristics of renal transplant recipients. Methods: It is a documentary and retrospective study that was performed at the renal transplantation ambulatory from the Hospital Geral de Fortaleza (HGF), Fortaleza city, Ceará State, with patients hospitalized from June 2012 to June 2014. The sample consisted of 300 patients submitted to renal transplantation. The predictive variables of interest were subdivided in the following categories: pre-transplant characteristics, post-transplant characteristics and immunological characteristics. Pearson and Spearman tests were used to evaluate the correlation between variables. Results: There was a predominance of male patients (65%), with ages ranging from 44 to 56 years (31.4%). A statistically significant relationship was found between the Donor-Specific Antibody and Delayed Graft Function (p<0.04), Cellular Rejection and PanelReactive Antibody class I (p<0.05), duration of hospitalization and Delayed Graft Function (p<0.001) and also between the Human Leukocyte Antigen and MISMATCH. Conclusion: It is pointed out the need for a critical and individualized follow-up of the transplanted patient by the professionals to guarantee the long-term transplantation success


Objetivo: Evaluar las características clínicas e inmunológicas de lós receptores de trasplante renal. Métodos: estudio documental y retrospectivo realizado en una clínica del Hospital General de Fortaleza, Fortaleza, Ceará, Brasil, con pacientes ingresados desde junio de 2012 a junio de 2014. La muestra fue de 300 pacientes sometidos a trasplante de riñón. Las variables predictoras de interés, fueron subdivididas en: características pretrasplante, características post-transplante y características inmunológicas. Se utilizaron pruebas de Pearson y Spearman para evaluar la correlación entre variables. Resultados: Hubo un predominio de pacientes del sexo masculino (65%), con edades comprendidas entre 44 y 56 años (31,4%). Se demostró una relación estadísticamente significativa entre el DSA y la disfunción del injerto (p <0,04), el rechazo celular del panel reactivo clase I (p <0,05), el tiempo de internación y la disfunción del injerto (p <0,001) y entre el HLA y el MISMATCH. Conclusión: Se apunta la necesidad de un acompañamiento crítico e individualizado del paciente trasplantado por parte de los profesionales para garantizar el éxito del trasplante a largo plazo


Assuntos
Humanos , Masculino , Feminino , Imunologia de Transplantes , Transplante de Rim/estatística & dados numéricos , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Brasil , Rejeição de Enxerto/epidemiologia
4.
West Afr J Med ; 36(3): 280-282, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31622492

RESUMO

The advent of direct-acting anti-virals revolutionized the treatment and prognosis of patients infected with hepatitis C. The interest of this presentation is to draw attention to the issue of therapeutic management posed by the hepatitis C virus in a kidney graft in Côte d'Ivoire, a resource-limited country where all the direct-acting anti-virals are not yet available. We report the case of a kidney transplant of 52 years old, chronic carrier of viral hepatitis C who presented after his kidney transplant in decompensated active cirrhosis. A treatment based on Sofosbuvir 400 mg/Ledipasvir 90 mg in this patient with genotype 2 for 12 weeks was initiated. Sustained virologic response 12 weeks and 24 weeks off therapy was observed. This is the first documented case of successful treatment of a genotype 2 viral C infection based on Sofosbuvir/Ledipasvir in a black African cirrhotic kidney transplant patient undergoing immunosuppressive therapy.


Assuntos
Antivirais/uso terapêutico , Benzimidazóis/uso terapêutico , Fluorenos/uso terapêutico , Hepacivirus/isolamento & purificação , Hepatite C Crônica/tratamento farmacológico , Transplante de Rim , Sofosbuvir/uso terapêutico , Antivirais/efeitos adversos , Benzimidazóis/efeitos adversos , Quimioterapia Combinada , Fluorenos/efeitos adversos , Genótipo , Hepacivirus/genética , Hepatite C Crônica/genética , Humanos , Masculino , Pessoa de Meia-Idade , Sofosbuvir/efeitos adversos , Resultado do Tratamento
5.
Medicine (Baltimore) ; 98(38): e17312, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31568017

RESUMO

Kidney transplantation (KT) is the best therapy available for patients with end-stage renal disease, but postoperative infections are a significant cause of mortality.In this retrospective study the frequency, risk factors, causative pathogens, and clinical manifestations of infection in KT recipients from Beijing Chao-Yang Hospital, Capital Medical University were investigated. Ninety-seven KT recipients who were hospitalized with infection between January 2010 and December 2016 were included. Clinical characteristics, surgery details, laboratory results, and etiology were compared in patients who developed single infection and patients who developed repeated infection (2 or more) after KT.A total of 161 infections were adequately documented in a total of 97 patients, of which 57 patients (58.8%) had 1 infection, 24 (24.7%) had 2, 11 (11.3%) had 3; 3 (3.1%) had 4, and 2 (2.1%) had 5 or more. The most common infection site was the urinary tract (90 infections; 56%), both overall and in the repeated infection group. The most frequently isolated pathogen was Pseudomonas aeruginosa. In the repeated infection patients, in most cases of P. aeruginosa infection (54%) it was cultured from urine. For first infections, a time between KT and infection of ≤ 21 days (area under receiver operating characteristic curve [AUC] 0.636) and a tacrolimus level ≥ 8 ng/mL (AUC 0.663) independently predicted repeat infection. The combination of these two predictive factors yielded an AUC of 0.716, which did not differ statistically significantly from either predictor alone.With regard to first infections after KT, a time between KT and infection of ≤ 21 days, and a tacrolimus level ≥ 8 ng/mL each independently predicted repeated infection in KT recipients.


Assuntos
Transplante de Rim/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Adulto , Feminino , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/microbiologia , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Infecções Urinárias/microbiologia
7.
Am J Bioeth ; 19(11): 27-29, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31661419
8.
Rev Col Bras Cir ; 46(4): e20192224, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31644721

RESUMO

OBJECTIVE: to evaluate the oral conditions and the main predisposing factors for dental treatment of patients on the waiting list for liver and simultaneous pancreas-kidney transplantation, in a single center. METHODS: we evaluated 100 patients in the waiting list, 50 candidates for liver transplantation and 50 for simultaneous kidney-pancreas transplantation, from August 2015 to February 2018. We correlated extra and intraoral examinations with pre-transplant demographic variables. RESULTS: the main oral alteration in the pancreas-kidney and liver transplant candidates were decayed, lost and filled teeth, present in 83% and 100% of the candidates, respectively (p=0.03). The need for dental treatment was equal in both groups: 71% and 70%. In liver transplant candidates, the predisposing factors for dental treatment were age, color and etiological diagnosis of liver cirrhosis. We did not identify predisposing factors for dental treatment in candidates for simultaneous pancreas-kidney transplant. CONCLUSION: candidates for liver and for simultaneous pancreas-kidney transplantation had poor oral hygiene, with cavities, residual roots, gingivitis and periodontitis, revealing that dental evaluation should be part of the transplantation waiting list.


Assuntos
Cárie Dentária , Transplante de Rim , Transplante de Fígado , Saúde Bucal , Transplante de Pâncreas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Listas de Espera
9.
Am Surg ; 85(9): 1066-1072, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638526

RESUMO

To assess renal transplant outcomes after donation by kidney-only (KO) versus multiple-organ (MO) donors on a national scale. The United Network for Organ Sharing database was examined for patients undergoing isolated kidney transplant from a deceased donor from 2000 through 2016. Comparison was made between recipients of grafts from KO versus MO donors at baseline and in a cohort of KO and MO recipients matched via propensity scoring. Outcomes of interest included delayed graft function (DGF), patient survival, and the cumulative incidence of graft loss. There were 33,326 recipients in the KO cohort versus 144,690 in the MO cohort. Donation after cardiac death donors were more prevalent in the KO group (43.8% vs 5.3%; P < 0.001). DGF occurred in 36.1 per cent of the KO versus 22.7 per cent of the MO recipients (P < 0.001). Five-year survival was 79.5 per cent versus 83.4 per cent (P < 0.001) in the KO versus MO group. After propensity matching, DGF was still more common in the KO group (33.1% vs 30.1%; P < 0.001). Patient survival was similar (79.5% KO vs 80.1% MO; P = 0.117). Cumulative incidence of graft loss was higher in the KO group (17.8% vs 16.8%). Survival outcomes from KO donors are actually quite good and should not be considered as inferior to MO donors.


Assuntos
Transplante de Rim , Doadores de Tecidos , Cadáver , Sobrevivência de Enxerto , Humanos , Tempo de Internação , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento
11.
Rev Med Liege ; 74(10): 521-526, 2019 Oct.
Artigo em Francês | MEDLINE | ID: mdl-31609555

RESUMO

The role of medical imaging is of major impor¬tance in the follow-up of patients with kidney transplant.There as many and various renal transplant complications. The development of techniques in medical imaging, especially the progression of clinical and biological monitoring improve their detection. In this article, we will remind the diverses complications of renal transplant and their expression in the various imaging modalities, including Doppler ultrasound which remains the principal examination modality.


Assuntos
Nefropatias , Transplante de Rim , Angiografia , Humanos , Nefropatias/cirurgia , Transplante de Rim/efeitos adversos , Complicações Pós-Operatórias , Ultrassonografia
14.
Orv Hetil ; 160(37): 1471-1475, 2019 Sep.
Artigo em Húngaro | MEDLINE | ID: mdl-31495189

RESUMO

The management of the abdominal aortic aneurysm is associated with several risk factors, especially in patients after renal transplantation. Endovascular aneurysm repair (EVAR) can be the proper treatment in feasible cases. The authors present a patient's case who underwent renal transplantation and developed an infrarenal aortic aneurysm some years later. A 50-year-old male patient was operated with EVAR. During the starting period of the procedure bilateral iliac dissection developed, and the endovascular approach was converted into traditional open operation. At the time when the aorta was clamped, an extraanatomic shunt was applied to ensure the blood supply of the transplanted organ. In the early postoperative period, a transient renal function impairment was observed. Later on, the renal function returned to normal values. In this article, alternative methods used to prevent ischaemic damage of the transplanted organ during the procedure are presented as well. Finally, the authors report the international trends and experiences in the field of preserving the viability of a transplanted organ during abdominal aneurysm repairs. Orv Hetil. 2019; 160(37): 1471-1475.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares/métodos , Aneurisma Ilíaco/cirurgia , Transplante de Rim , Humanos , Artéria Ilíaca/cirurgia , Transplante de Rim/efeitos adversos , Masculino , Resultado do Tratamento
15.
Medicine (Baltimore) ; 98(36): e16995, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31490381

RESUMO

RATIONALE: Active tuberculosis constitutes a relevant risk for kidney transplant recipients. In contrast to immunocompetent hosts, kidney transplant recipients often show atypical presentation and course of the disease impeding diagnosis. Especially extrapulmonary or disseminated infection is more frequent and can resemble malignant processes. However, reactivation of tuberculosis mostly develops within the early post-transplant course, whereas malignancies are predominantly long-term complications. We report a case of disseminated abdominal tuberculosis developing 10 years after kidney transplantation and review the underlying literature. PATIENT CONCERNS AND DIAGNOSES: A 51-year-old lady presented with epigastric pain, diarrhea, weight loss and night sweats 10 years after deceased-donor kidney transplantation. An epigastric as well as multiple peritoneal masses were found suspicious of a cancer of unknown primary. Colonoscopy revealed a colon tumor with the biopsy showing no dysplasia but histiocytic and granulomatous infiltration with acid-fast bacilli. Mycobacterium tuberculosis was detected in the biopsy and stool and disseminated abdominal tuberculosi was diagnosed. INTERVENTIONS AND OUTCOMES: With anti-tuberculosis therapy, the masses regressed, and all cultures became sterile, sparing graft function. LESSONS: This case emphasizes how variable and unspecific the presentation of tuberculosis in kidney transplant recipients may be and that tuberculosis constitutes a relevant risk also in the long-term post-transplant course.


Assuntos
Neoplasias do Colo/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Tuberculose Gastrointestinal/diagnóstico , Antituberculosos/uso terapêutico , Diagnóstico Diferencial , Feminino , Humanos , Transplante de Rim , Pessoa de Meia-Idade , Tuberculose Gastrointestinal/tratamento farmacológico
16.
Medicine (Baltimore) ; 98(37): e17006, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31517819

RESUMO

CD200 is an immunoglobulin superfamily membrane protein that binds to a myeloid cell-specific receptor and induces inhibitory signaling. The aim of this study was to investigate the role of CD200 and its receptor (CD200R1) on kidney transplant (KTx) outcome. In a collective of 125 kidney recipients (University hospital, Heidelberg, Germany), CD200 and CD200R1 concentrations were evaluated immediately before transplantation. Recipient baseline and clinical characteristics and KTx outcome, including acute rejection (AR), acute tubular necrosis, delayed graft function, cytomegalovirus (CMV) and human polyomaviridae (BK) virus infections, and graft loss were evaluated during the first post-transplant year. The association of CD200 and CD200R1 concentrations and CD200R1/CD200 ratios with the outcome of KTx was investigated for the first time in a clinical setting in a prospective cohort. There was a positive association between pre-transplant CD200R1 concentrations and CMV (re)activation (P = .041). Also, increased CD200R1 concentration was associated with a longer duration of CMV infection (P = .049). Both the frequency of AR and levels of creatinine (3 and 6 months after KTx) were significantly higher in patients with an increased CD200R1/CD200 ratio (median: 126 vs 78, P = .008). Increased pre-transplant CD200R1/CD200 ratios predict immunocompetence and risk of AR, whereas high CD200R1 concentrations predict immunosuppression and high risk of severe CMV (re)activation after KTx.


Assuntos
Antígenos CD/sangue , Antígenos de Superfície/sangue , Falência Renal Crônica/sangue , Falência Renal Crônica/cirurgia , Transplante de Rim , Complicações Pós-Operatórias/diagnóstico , Receptores de Superfície Celular/sangue , Adulto , Idoso , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Prognóstico , Estudos Prospectivos , Adulto Jovem
18.
JAMA ; 322(10): 957-973, 2019 09 10.
Artigo em Inglês | MEDLINE | ID: mdl-31503308

RESUMO

Importance: For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population. Objective: To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Design, Setting, and Participants: Retrospective cohort study that included 1 478 564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report). Exposures: The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities. Main Outcomes and Measures: Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome. Results: Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: -13.2% [95% CI, -13.4% to -13.0%]; receipt of a living donor kidney transplant: -2.3% [95% CI, -2.4% to -2.3%]; and receipt of a deceased donor kidney transplant: -4.3% [95% CI, -4.4% to -4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]). Conclusions and Relevance: Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.


Assuntos
Instituições Privadas de Saúde , Acesso aos Serviços de Saúde , Falência Renal Crônica/terapia , Transplante de Rim , Propriedade , Diálise Renal , Humanos , Doadores Vivos , Diálise Renal/economia , Estudos Retrospectivos , Estados Unidos , Listas de Espera
19.
BMJ ; 366: l4923, 2019 09 17.
Artigo em Inglês | MEDLINE | ID: mdl-31530561

RESUMO

OBJECTIVE: To develop and validate an integrative system to predict long term kidney allograft failure. DESIGN: International cohort study. SETTING: Three cohorts including kidney transplant recipients from 10 academic medical centres from Europe and the United States. PARTICIPANTS: Derivation cohort: 4000 consecutive kidney recipients prospectively recruited in four French centres between 2005 and 2014. Validation cohorts: 2129 kidney recipients from three centres in Europe and 1428 from three centres in North America, recruited between 2002 and 2014. Additional validation in three randomised controlled trials (NCT01079143, EudraCT 2007-003213-13, and NCT01873157). MAIN OUTCOME MEASURE: Allograft failure (return to dialysis or pre-emptive retransplantation). 32 candidate prognostic factors for kidney allograft survival were assessed. RESULTS: Among the 7557 kidney transplant recipients included, 1067 (14.1%) allografts failed after a median post-transplant follow-up time of 7.12 (interquartile range 3.51-8.77) years. In the derivation cohort, eight functional, histological, and immunological prognostic factors were independently associated with allograft failure and were then combined into a risk prediction score (iBox). This score showed accurate calibration and discrimination (C index 0.81, 95% confidence interval 0.79 to 0.83). The performance of the iBox was also confirmed in the validation cohorts from Europe (C index 0.81, 0.78 to 0.84) and the US (0.80, 0.76 to 0.84). The iBox system showed accuracy when assessed at different times of evaluation post-transplant, was validated in different clinical scenarios including type of immunosuppressive regimen used and response to rejection therapy, and outperformed previous risk prediction scores as well as a risk score based solely on functional parameters including estimated glomerular filtration rate and proteinuria. Finally, the accuracy of the iBox risk score in predicting long term allograft loss was confirmed in the three randomised controlled trials. CONCLUSION: An integrative, accurate, and readily implementable risk prediction score for kidney allograft failure has been developed, which shows generalisability across centres worldwide and common clinical scenarios. The iBox risk prediction score may help to guide monitoring of patients and further improve the design and development of a valid and early surrogate endpoint for clinical trials. TRIAL REGISTRATION: Clinicaltrials.gov NCT03474003.


Assuntos
Rejeição de Enxerto/etiologia , Transplante de Rim , Adulto , Idoso , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Prognóstico , Reprodutibilidade dos Testes , Medição de Risco/métodos , Estados Unidos/epidemiologia
20.
Ann R Coll Surg Engl ; 101(8): 609-616, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31508984

RESUMO

INTRODUCTION: Hypothermic machine perfusion, an organ preservation modality, involves flow of chilled preservation fluid through an allograft's vasculature. This study describes a simple, reproducible, human model that allows for interrogation of flow effects during ex vivo organ perfusion. MATERIALS AND METHODS: Gonadal veins from deceased human renal allografts were subjected to either static cold storage or hypothermic machine perfusion for up to 24 hours. Caspase-3, Krüppel-like factor 2 expression and electron microscopic analysis were compared between 'flow' and 'no-flow' conditions, with living donor gonadal vein sections serving as negative controls. RESULTS: The increase in caspase-3 expression was less pronounced for hypothermic machine-perfused veins compared with static cold storage (median-fold increase 1.2 vs 2.3; P < 0.05). Transmission electron microscopy provided ultrastructural corroboration of endothelial cell apoptosis in static cold storage conditions. For static cold storage preserved veins, Krüppel-like factor 2 expression diminished in a time-dependent manner between baseline and 12 hours (P < 0.05) but was abrogated and reversed by hypothermic machine perfusion (P < 0.05). CONCLUSIONS: Our methodology is a simple, reproducible and successful model of ex vivo perfusion in the context of human organ preservation. To demonstrate the model's utility, we establish that two widely used markers of endothelial health (caspase-3 and Krüppel-like factor 2) differ between the flow and no-flow conditions of the two predominant kidney preservation modalities. These findings suggest that ex vivo perfusion may mediate the induction of a biochemically favourable endothelial niche which may contribute tohypothermic machine perfusion's association with improved renal transplantation outcomes.


Assuntos
Transplante de Rim/métodos , Rim/irrigação sanguínea , Modelos Biológicos , Soluções para Preservação de Órgãos/farmacocinética , Preservação de Órgãos/métodos , Apoptose , Biomarcadores/metabolismo , Cadáver , Caspase 3/metabolismo , Temperatura Baixa , Endotélio Vascular/metabolismo , Humanos , Rim/metabolismo , Rim/ultraestrutura , Fatores de Transcrição Kruppel-Like/metabolismo , Microscopia Eletrônica , Perfusão/métodos , Veias/metabolismo , Veias/ultraestrutura
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