Qualidade de vida de pacientes que retornam a Hemodiálise após serem submetidos a um transplante renal / Quality of life of patients returning hemodialysic after submitting a renal transplant

Introdução: A Doença Renal Crônica (DRC) é caracterizada pela perda gradual e irreversível da função renal, esse fato ocorre quando os rins deixam de remover os produtos metabólicos produzidos pelo corpo ou de realizar sua função reguladora. O transplante renal envolve transplantar o rim de um doador vivo ou falecido para um receptor que não apresenta mais função renal. Objetivo: Avaliar a qualidade de vida de pessoas que retornaram a hemodiálise após transplante renal. Métodos: Pesquisa de abordagem qualitativa, do tipo estudo de caso. Utilizou-se de uma entrevista semiestruturada e o instrumento de avaliação de qualidade de vida da Organização Mundial de Saúde, WHOQOL-100.Foram entrevistadosdois pacientes, recrutados por meio do contato com o serviço de Nefrologiaonde os mesmosrealizavam o tratamento dialítico.Resultados: A entrevista demonstrou que o diagnóstico de rejeição do órgão é um dos momentos mais difíceis para o paciente, a assistência da família durante o tratamento é de fundamental importância, as restrições dietéticas e hídricas tornam-se uma carga a mais durante o tratamento e as expectativas futuras possivelmente serão menores considerando a fase da vida em que esse diagnóstico é constatado. No WHOQOL-100, os entrevistados apresentam níveis iguais ou acima da média de qualidade de vida, sendo apenas o domínio de nível de independência odemenor escore. Conclusão: A pesquisa enfatiza a necessidade de uma atenção profissional humanista e acolhedora, visto que esse retorno a hemodiálise após passar pelo transplante pode ocasionar um impacto negativo nas dimensões físicas, psíquicas e sociais das pessoas que voltam a realizar hemodiálise (AU).

Introduction: Chronic Kidney Disease (CKD) is characterized by the gradual and irreversible loss of renal function,this occurs when the kidneys fail to remove the metabolic products produced by the body or to perform its regulatory function. Kidney transplantation involves transplanting the kidney from a living or deceased donor to a recipient who has no kidney function.Objective: To evaluate the quality of life of people who returned to hemodialysis after a kidney transplant.Methods: Qualitative research, case study type. It used a semistructured interview and the assessment tool of quality of life of the World Health Organization, WHOQOL-100.Two patients were interviewed, recruited through contact with the Nephrology service where they performed the dialysis treatment.Results: The interview demonstrated that the diagnosis of rejection of the organ is one of the most difficult moments for the patient, the family assistance in treatment is of fundamental importance, dietary and water restrictions become overloaded during the treatment and the future expectations possibly will be smaller considering the stage of life in which the diagnosis is established. The WHOQOL100, the interviewees feature levels equal to or above the average quality of life, being only the domain of independence level with the lowest score.Conclusion: The research emphasizes the need for a professional humanist and friendly attention, Since this return to dialysis after passing by the transplant can cause a negative impact on physical, psychological and social dimensions, of the people who come back to perform hemodialysis (AU).

Upregulation of microRNA 142-3p in the peripheral blood and urinary cells of kidney transplant recipients with post-transplant graft dysfunction

We analyzed microRNA (miR)-142-3p expression in leucocytes of the peripheral blood and urinary sediment cell samples obtained from kidney transplant recipients who developed graft dysfunction. Forty-one kidney transplant recipients with kidney graft dysfunction and 8 stable patients were included in the study. The groups were divided according to histological analysis into acute rejection group (n=23), acute tubular necrosis group (n=18) and stable patients group used as a control for gene expression (n=8). Percutaneous biopsies were performed and peripheral blood samples and urine samples were obtained. miR-142-3p was analyzed by real-time polymerase chain reaction. The group of patients with acute tubular necrosis presented significantly higher expressions in peripheral blood (P<0.05) and urine (P<0.001) compared to the stable patients group. Also, in the peripheral blood, miR-142-3p expression was significantly higher in the acute tubular necrosis group compared to the acute rejection group (P<0.05). Urine samples of the acute rejection group presented higher expression compared to the stable patients group (P<0.001) but the difference between acute tubular necrosis and acute rejection groups was not significant in the urinary analyzes (P=0.079). miR-142-3p expression has a distinct pattern of expression in the setting of post-operative acute tubular necrosis after kidney transplantation and may potentially be used as a non-invasive biomarker for renal graft dysfunction.

Prognostic factors for the evolution and reversibility of chronic rejection in pediatric liver transplantation

OBJECTIVE: Chronic rejection remains a major cause of graft failure with indication for re-transplantation. The incidence of chronic rejection remains high in the pediatric population. Although several risk factors have been implicated in adults, the prognostic factors for the evolution and reversibility of chronic rejection in pediatric liver transplantation are not known. Hence, the current study aimed to determine the factors involved in the progression or reversibility of pediatric chronic rejection by evaluating a series of chronic rejection cases following liver transplantation. METHODS: Chronic rejection cases were identified by performing liver biopsies on patients based on clinical suspicion. Treatment included maintaining high levels of tacrolimus and the introduction of mofetil mycophenolate. The children were divided into 2 groups: those with favorable outcomes and those with adverse outcomes. Multivariate analysis was performed to identify potential risk factors in these groups. RESULTS: Among 537 children subjected to liver transplantation, chronic rejection occurred in 29 patients (5.4%). In 10 patients (10/29, 34.5%), remission of chronic rejection was achieved with immunosuppression (favorable outcomes group). In the remaining 19 patients (19/29, 65.5%), rejection could not be controlled (adverse outcomes group) and resulted in re-transplantation (7 patients, 24.1%) or death (12 patients, 41.4%). Statistical analysis showed that the presence of ductopenia was associated with worse outcomes (risk ratio=2.08, p=0.01). CONCLUSION: The presence of ductopenia is associated with poor prognosis in pediatric patients with chronic graft rejection.

Reduced Progression of Cardiac Allograft Vasculopathy with Routine Use of Induction Therapy with Basiliximab / Redução da Progressão da Doença Vascular do Enxerto Cardíaco com o Uso Rotineiro da Terapia de Indução com Basiliximab

AbstractIntroduction:Cardiac allograft vasculopathy (CAV) is a major limitation for long-term survival of patients undergoing heart transplantation (HT). Some immunosuppressants can reduce the risk of CAV.Objectives:The primary objective was to evaluate the variation in the volumetric growth of the intimal layer measured by intracoronary ultrasound (IVUS) after 1 year in patients who received basiliximab compared with that in a control group.Methods:Thirteen patients treated at a single center between 2007 and 2009 were analyzed retrospectively. Evaluations were performed with IVUS, measuring the volume of a coronary segment within the first 30 days and 1 year after HT. Vasculopathy was characterized by the volume of the intima of the vessel.Results:Thirteen patients included (7 in the basiliximab group and 6 in the control group). On IVUS assessment, the control group was found to have greater vessel volume (120–185.43 mm3 vs. 127.77–131.32 mm3; p = 0.051). Intimal layer growth (i.e., CAV) was also higher in the control group (27.30–49.15 mm3 [∆80%] vs. 20.23–26.69 mm3[∆33%]; p = 0.015). Univariate regression analysis revealed that plaque volume and prior atherosclerosis of the donor were not related to intima growth (r = 0.15, p = 0.96), whereas positive remodeling was directly proportional to the volumetric growth of the intima (r = 0.85, p < 0.001).Conclusion:Routine induction therapy with basiliximab was associated with reduced growth of the intima of the vessel during the first year after HT.

ResumoFundamento:A doença vascular do enxerto (DVE) constitui uma grande limitação de sobrevida a longo prazo de pacientes submetidos a transplante cardíaco (TxC). Alguns imunossupressores diminuem o aparecimento da DVE.Objetivos:O principal objetivo foi avaliar, através de ultrassonografia intracoronária (USIC), a variação do crescimento volumétrico da camada íntima e comparar, após um ano, o grupo que recebeu basiliximab com um grupo de controle.Métodos:Treze pacientes de um único centro foram analisados retrospectivamente de 2007 a 2009. As análises foram feitas através de USIC, medindo-se o volume de um segmento coronariano nos primeiros 30 dias e um ano após o TxC. A vasculopatia foi caracterizada pelo volume da camada íntima do vaso.Resultados:O estudo incluiu 13 pacientes (7 no grupo com o basiliximab e 6 no grupo de controle). A análise por USIC revelou que o grupo de controle apresentou maior crescimento volumétrico do vaso (131,32 a 127,77 mm3 x 120 a 185,43 mm3 p = 0,051). O crescimento da camada íntima (CCI) também foi maior no grupo de controle [Basiliximab: 20,23 a 26,69 mm3 (∆ 33%); Controle: 27,30 a 49,15 mm3(∆ 80% p = 0,015)]. De acordo com a regressão univariada, o volume da placa aterosclerótica prévia do doador não teve relação com o crescimento da íntima (r = 0,15, p = 0,96), enquanto que o remodelamento positivo do vaso foi diretamente proporcional ao crescimento da íntima (r = 0,85, p < 0,001).Conclusão:A terapia de indução de rotina com basiliximab está associada à redução do crescimento da camada íntima do vaso no primeiro ano após o transplante cardíaco.

Instrument to assess the nursing care product: development and content validation / Instrumento para avaliação do produto do cuidar em enfermagem: desenvolvimento e validação de conteúdo / Instrumento para evaluación del producto del cuidar en enfermería: desarrollo y validación de contenido

AbstractObjectives: develop and validate the content of a tool about nursing care production.Method: the data were collected between 2011 and 2013, based on focus groups, the application of semistructured questionnaires (prototype test) and the Delphi technique. The focus groups were used to produce the instrument items and held at three hospitals in the interior of the State of São Paulo, involving 20 nurses. A panel of 10 experts evaluated the instrument.Results: after two phases of the Delphi technique, the tool consisted of eight items. The content validity index of the scale corresponded to ≥0.9 and the content validity of the items ranged between 0.8 and 1.0, indicating the maintenance of the structure and content. The assertion on the applicability in daily nursing practice showed a content validity index of the scale equal to 0.8.Conclusion: this study permitted the development and content validation of scale on nursing care production, equipping the nurses in their management practice.

ResumoObjetivos:desenvolver e validar o conteúdo de um instrumento sobre produção do cuidado de enfermagem.Método:a coleta de dados ocorreu entre 2011 e 2013, a partir de grupos focais, aplicação de questionários semiestruturados (teste do protótipo) e técnica Delphi. Os grupos focais foram utilizados para geração de itens do instrumento e realizados em três hospitais do interior do Estado de São Paulo, com a participação de 20 enfermeiros. A apreciação do instrumento foi conduzida por um painel de 10 especialistas.Resultados:após duas fases da técnica Delphi, o instrumento passou a ser constituído por oito itens. O índice de validade do conteúdo da escala foi de ≥0,9 e a validade dos conteúdos dos itens apresentou variação de 0,8 a 1,0, indicando a manutenção da estrutura e do conteúdo. A afirmativa referente à aplicabilidade na prática diária do enfermeiro apresentou índice de validade do conteúdo da escala de 0,8.Conclusão:este estudo possibilitou desenvolver e validar o conteúdo de uma escala sobre produção do cuidado de enfermagem, instrumentalizando os enfermeiros em sua prática gerencial.

ResumenObjetivos:desarrollar y validar el contenido de un instrumento sobre producción del cuidado de enfermería.Método:los datos fueron recolectados entre 2011 y 2013, a partir de grupos focales, aplicación de cuestionarios semiestructurados (prueba del prototipo) y técnica Delphi. Los grupos focales fueron utilizados para generar ítems del instrumento y organizados en tres hospitales del interior del Estado de São Paulo, con la participación de 20 enfermeros. La apreciación del instrumento fue conducida por un panel de 10 especialistas.Resultados:tras dos fases de la técnica Delphi, el instrumento pasó a ser constituido por ocho ítems. El índice de validez de contenido de la escala fue ≥0,9 y la validez de los contenidos mostró variación de 0,8 a 1,0, indicando la manutención de la estructura y del contenido. La afirmativa respecto a la aplicabilidad en la práctica diaria del enfermero mostró índice de validez del contenido de la escala de 0,8.Conclusión:este estudio permitió desarrollar y validar el contenido de una escala sobre producción del cuidado de enfermería, instrumentalizando los enfermeros en su práctica gerencial.

Avaliação da doença vascular do enxerto no transplante cardíaco: experiência de um centro brasileiro / Assessment of cardiac allograft vasculopathy in cardiac transplantation: experience of a Brazilian center

FUNDAMENTO: O transplante cardíaco continua sendo o tratamento de escolha para a insuficiência cardíaca refratária ao tratamento otimizado. Dois métodos diagnósticos apresentam elevada sensibilidade no diagnóstico de episódios de rejeição ao enxerto e Doença Vascular do Enxerto (DVE), causas importantes de mortalidade no pós-transplante. OBJETIVO: Avaliar a relação entre os resultados do ultrassom intracoronariano (USIV) e os laudos das biópsias endomiocárdicas (BX) no seguimento de pacientes submetidos a transplante cardíaco em um serviço de referência brasileiro. MÉTODOS: Foi realizado um ensaio epidemiológico retrospectivo observacional, com pacientes submetidos a transplante cardíaco ortotópico, no período de 2000 a 2009. Foram analisados os prontuários desses pacientes e os resultados dos USIV e BX realizados rotineiramente no seguimento clínico pós-transplante e terapêutica em uso. RESULTADOS: Dos 77 pacientes analisados, 63,63% são do sexo masculino, nas faixas etárias de 22 a 69 anos. Quanto aos resultados dos USIV, 33,96% foram classificados em Stanford classe I, e 32,08%, como Stanford IV. Dos 143 laudos das biópsias, 51,08% tiveram resultado 1R, 3R em 0,69% dos laudos, e 14,48% apresentaram a descrição de efeito Quilty. Todos usaram antiproliferativos, 80,51% usaram inibidores da calcineurina e 19,48% usaram inibidores do sinal de proliferação (ISP). CONCLUSÃO: A avaliação dos pacientes pós-transplante cardíaco por meio do USIV incorpora informações detalhadas para o diagnóstico precoce e sensível da DVE, que são complementadas pelas informações histológicas fornecidas pelas BX, estabelecendo uma possível relação causal entre a DVE e os episódios de rejeição humoral.

BACKGROUND: Cardiac transplantation continues to be the treatment of choice for heart failure refractory to optimized treatment. Two methods have high sensitivity for diagnosing allograft rejection episodes and cardiac allograft vasculopathy (CAV), important causes of mortality after transplantation. OBJECTIVE: To assess the relationship between intravascular ultrasound (IVUS) results and endomyocardial biopsy (BX) reports in the follow-up of patients undergoing cardiac transplantation in a Brazilian reference service. METHODS: A retrospective epidemiological observational study was carried out with patients undergoing orthotopic cardiac transplantation from 2000 to 2009. The study assessed the medical records of those patients and the results of the IVUS and BX routinely performed in the clinical post-transplant follow-up, as well as the therapy used. RESULTS: Of the 77 patients assessed, 63.63% were males, their ages ranging from 22 to 69 years. Regarding the IVUS results, 33.96% of the patients were classified as Stanford class I, and 32.08%, as Stanford class IV. Of the 143 BX reports, 51.08% were 1R, and 0.69%, 3R. The Quilty effect was described in 14.48% of the BX reports. All patients used antiproliferative agents, 80.51% used calcineurin inhibitors, and 19.48% used proliferation signal inhibitors. CONCLUSION: The assessment of cardiac transplant patients by use of IVUS provides detailed information for the early and sensitive diagnosis of CAV, which is complemented by histological data derived from BX, establishing a possible causal relationship between CAV and humoral rejection episodes.

Glomerular damage as a predictor of renal allograft loss

Interstitial fibrosis and tubular atrophy (IF/TA) are the most common cause of renal graft failure. Chronic transplant glomerulopathy (CTG) is present in approximately 1.5-3.0 percent of all renal grafts. We retrospectively studied the contribution of CTG and recurrent post-transplant glomerulopathies (RGN) to graft loss. We analyzed 123 patients with chronic renal allograft dysfunction and divided them into three groups: CTG (N = 37), RGN (N = 21), and IF/TA (N = 65). Demographic data were analyzed and the variables related to graft function identified by statistical methods. CTG had a significantly lower allograft survival than IF/TA. In a multivariate analysis, protective factors for allograft outcomes were: use of angiotensin-converting enzyme inhibitor (ACEI; hazard ratio (HR) = 0.12, P = 0.001), mycophenolate mofetil (MMF; HR = 0.17, P = 0.026), hepatitis C virus (HR = 7.29, P = 0.003), delayed graft function (HR = 5.32, P = 0.016), serum creatinine ≥1.5 mg/dL at the 1st year post-transplant (HR = 0.20, P = 0.011), and proteinuria ≥0.5 g/24 h at the 1st year post-transplant (HR = 0.14, P = 0.004). The presence of glomerular damage is a risk factor for allograft loss (HR = 4.55, P = 0.015). The presence of some degree of chronic glomerular damage in addition to the diagnosis of IF/TA was the most important risk factor associated with allograft loss since it could indicate chronic active antibody-mediated rejection. ACEI and MMF were associated with better outcomes, indicating that they might improve graft survival.

Synergistic effect of mycophenolate mofetil and angiotensin-converting enzyme inhibitor in patients with chronic allograft nephropathy

Experimental data and few clinical non-randomized studies have shown that inhibition of the renin-angiotensin system by angiotensin-converting enzyme (ACE) associated or not with the use of mycophenolate mofetil (MMF) could delay or even halt the progression of chronic allograft nephropathy (CAN). In this retrospective historical study, we investigated whether ACE inhibition (ACEI) associated or not with the use of MMF has the same effect in humans as in experimental studies and what factors are associated with a clinical response. A total of 160 transplant patients with biopsy-proven CAN were enrolled. Eighty-one of them were on ACE therapy (G1) and 80 on ACEI_free therapy (G2). Patients were further stratified for the use of MMF. G1 patients showed a marked decrease in proteinuria and stabilized serum creatinine with time. Five-year graft survival after CAN diagnosis was more frequent in G1 (86.9 vs 67.7 percent; P < 0.05). In patients on ACEI-free therapy, the use of MMF was associated with better graft survival. The use of ACEI therapy protected 79 percent of the patients against graft loss (OR = 0.079, 95 percentCI = 0.015-0.426; P = 0.003). ACEI and MMF or the use of MMF alone after CAN diagnosis conferred protection against graft loss. This finding is well correlated with experimental studies in which ACEI and MMF interrupt the progression of chronic allograft dysfunction and injury. The use of ACEI alone or in combination with MMF significantly reduced proteinuria and stabilized serum creatinine, consequently improving renal allograft survival.

Are the current chronic allograft nephropathy grading systems sufficient to predict renal allograft survival?

A major problem in renal transplantation is identifying a grading system that can predict long-term graft survival. The present study determined the extent to which the two existing grading systems (Banff 97 and chronic allograft damage index, CADI) correlate with each other and with graft loss. A total of 161 transplant patient biopsies with chronic allograft nephropathy (CAN) were studied. The samples were coded and evaluated blindly by two pathologists using the two grading systems. Logistic regression analyses were used to evaluate the best predictor index for renal allograft loss. Patients with higher Banff 97 and CADI scores had higher rates of graft loss. Moreover, these measures also correlated with worse renal function and higher proteinuria levels at the time of CAN diagnosis. Logistic regression analyses showed that the use of angiotensin-converting enzyme inhibitor (ACEI), hepatitis C virus (HCV), tubular atrophy, and the use of mycophenolate mofetil (MMF) were associated with graft loss in the CADI, while the use of ACEI, HCV, moderate interstitial fibrosis and tubular atrophy and the use of MMF were associated in the Banff 97 index. Although Banff 97 and CADI analyze different parameters in different renal compartments, only some isolated parameters correlated with graft loss. This suggests that we need to review the CAN grading systems in order to devise a system that includes all parameters able to predict long-term graft survival, including chronic glomerulopathy, glomerular sclerosis, vascular changes, and severity of chronic interstitial fibrosis and tubular atrophy.