RESUMO
Glomerulonephritis (GN) is the leading cause of chronic kidney disease among recipients of renal transplants. Because modern immunosuppressive regimens have reduced the incidence of rejection-related graft loss, the probability and clinical significance of posttransplantation GN (PTGN) requires reevaluation. In this Canadian epidemiologic study, we monitored 2026 sequential renal transplant recipients whose original renal disease resulted from biopsy-proven GN (36%), from presumed GN (7.8%), or from disorders other than GN (56%) for 15 yr without loss to follow-up. Kaplan-Meier estimates of PTGN in the whole population were 5.5% at 5 yr, 10.1% at 10 yr, and 15.7% at 15 yr. PTGN was diagnosed in 24.3% of patients whose original renal disease resulted from biopsy-proven GN, compared with 11.8% of those with presumed GN and 10.5% of those with disorders other than GN. Biopsy-proven GN in the native kidney, male gender, younger age, and nonwhite ethnicity predicted PTGN. Current immunosuppressive regimens did not associate with a reduced frequency of PTGN. Patients who developed PTGN had significantly reduced graft survival (10.2 versus 69.7%; P < 0.0001). In summary, in the Canadian population, PTGN is a common and serious complication that causes accelerated graft failure, despite the use of modern immunosuppressive regimens.
Assuntos
Glomerulonefrite/epidemiologia , Nefropatias/cirurgia , Transplante de Rim/efeitos adversos , Canadá/epidemiologia , Etnicidade/estatística & dados numéricos , Feminino , Glomerulonefrite/mortalidade , Glomerulonefrite/cirurgia , Glomerulonefrite/terapia , Humanos , Imunossupressores/uso terapêutico , Nefropatias/classificação , Transplante de Rim/imunologia , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Probabilidade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Caracteres Sexuais , Análise de Sobrevida , Sobreviventes , Fatores de TempoRESUMO
Collapsing glomerulopathy (CG), a variant of idiopathic focal segmental glomerulosclerosis (FSGS), can occur in both human immunodeficiency virus (HIV)-positive and HIV-negative patients. Idiopathic membranous glomerulonephritis (MGN) has been reported to coexist with FSGS, but rarely with CG. We report 3 HIV-negative patients (2 men, 1 woman) who developed nephrotic syndrome secondary to MGN complicated by CG, with relatively rapid disease progression despite aggressive therapy.
Assuntos
Glomerulonefrite Membranosa/complicações , Glomerulosclerose Segmentar e Focal/complicações , Rim/patologia , Adulto , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Biópsia , Progressão da Doença , Feminino , Glomerulonefrite Membranosa/terapia , Glomerulosclerose Segmentar e Focal/terapia , Soronegatividade para HIV , Humanos , Imunossupressores/uso terapêutico , Masculino , Síndrome Nefrótica/etiologia , Síndrome Nefrótica/terapia , Ramipril/uso terapêutico , Terapia de Substituição Renal , Estudos RetrospectivosRESUMO
Cryocrystalglobulinaemia is an extremely rare complication of monoclonal gammopathy. Its presentation has features of both type I and II cryoglobulinaemia. Although peripheral and digital ischaemia is common, visceral ischaemia is rare. When it does occur, it is usually associated with multiple myeloma and has an extremely poor prognosis. We present a case of bilateral renal artery thrombosis associated with cryocrystalglobulinaemia in a patient without myeloma. More unusual, the cryocrystal protein in this case was associated with fibrinogen, which may have led to increased propensity towards thrombosis. Although the patient was unable to recover his kidney function, he remained alive on dialysis 2 years after the incident. The patient did not have any further ischaemic event despite no definitive therapy. This case represents an unusual presentation for this rare disease.
RESUMO
BACKGROUND: Diffuse peritubular capillary (PTC) C4d deposition has been shown to be associated with relatively poor graft outcome. The significance of focal PTC C4d staining in the early post-transplant period is uncertain. METHODS: Sixty-five biopsies from 53 patients with acute rejection were graded (Banff '97 criteria), stained for C4d, monocytes and T cells, and divided into three groups according to PTC C4d: (i) focal C4d (F) (14 biopsies, 14 patients), (ii) diffuse C4d (D) (23 biopsies, 15 patients) and (iii) no C4d (N) (28 biopsies, 24 patients). The three groups were compared with respect to a variety of biopsy and clinical parameters including outcome. RESULTS: The incidence of transplant glomerulitis and glomerular monocyte infiltration were significantly greater in F (64% and 2.0+/-2.0) and D (57% and 3.4+/-2.0) than in N (11% and 0.2+/-0.2). A significantly higher proportion of F (93%) demonstrated acute cellular rejection (Banff '97 grade > or = 1A) than did D (35%). The F and D groups included significantly more females (50 and 67%, respectively) than did N (21%). The percentage of patients with a second or third transplant was higher in F (29%) and D (40%) than in N (8%) (P = 0.0589). The proportion of patients with glomerular filtration rate < 30 ml/min at 12, 24 and 48 months was higher in the D and F groups than in the N, and there was a statistically significant increasing trend in odds of this outcome occurring at 48 months across the three groups (D > F > N group) (P = 0.0416). CONCLUSION: The results suggest that the biopsy findings and clinical course in patients with focal PTC C4d staining are similar to those associated with diffuse C4d.
Assuntos
Complemento C4b/metabolismo , Rejeição de Enxerto/patologia , Transplante de Rim/efeitos adversos , Túbulos Renais/química , Doença Aguda , Análise de Variância , Biomarcadores/análise , Biomarcadores/metabolismo , Biópsia por Agulha , Capilares , Distribuição de Qui-Quadrado , Estudos de Coortes , Complemento C4b/análise , Feminino , Humanos , Imuno-Histoquímica , Falência Renal Crônica/cirurgia , Túbulos Renais/irrigação sanguínea , Túbulos Renais/patologia , Masculino , Valor Preditivo dos Testes , Probabilidade , Prognóstico , Medição de Risco , Estudos de Amostragem , Sensibilidade e Especificidade , Fatores de TempoRESUMO
BACKGROUND: Renal injury is common after open-heart surgery. Cardiopulmonary bypass contributes to the problem. We compared conventional nonpulsatile perfusion (NP) to biologically variable perfusion (BVP), which uses a computer controller to restore physiological beat-to-beat variability to roller pump flow. We hypothesized BVP would decrease renal injury after deep hypothermic circulatory arrest. METHODS: Pigs were randomly assigned to either BVP (n = 9) or NP (n = 9), cooled, arrested at 18 degrees C (1 hour), reperfused, and rewarmed and maintained normothermic (3 hours). Additional pigs had NP for a similar time as above, but without circulatory arrest (n = 3), or were sham-treated without bypass (n = 3). Hemodynamics, acid-base status, temperature, and urine volumes were measured. Urinary enzyme markers of tubular injury were compared post-hoc for gamma glutamyl transpeptidase, alkaline phosphatase, and glutathione S-transferase and by urine proteomics using mass spectrometry. RESULTS: Urine output at 1 hour after arrest was 250 +/- 129 mL with BVP versus 114 +/- 66 mL with NP (p < 0.02). All three renal enzyme markers were higher with NP after arrest compared with BVP. In animals on bypass without arrest or those sham-treated, no elevations were seen in renal enzymes. Urine proteomics revealed abnormal proteins, persisting longer with NP. Biologically variable perfusion decreased cooling to 21.0 +/- 9.0 minutes versus 31.7 +/- 7.5 minutes (p < 0.002), and decreased rewarming to 22.1 +/- 3.9 minutes versus 31.2 +/- 5.1 minutes (p < 0.002). CONCLUSIONS: Biologically variable perfusion improved urine output, decreased enzymuria, and attenuated mass spectrometry urine protein signal with more rapid temperature changes. This strategy could potentially shorten bypass duration and may decrease renal tubular injury with deep hypothermic circulatory arrest.