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INTRODUCTION: Preterm prelabor rupture of membranes (PPROM) is a common complication after fetal surgeries. The aim of this study was to assess risk factors for and outcomes after PPROM following cord occlusion (CO) in monochorionic diamniotic (MCDA) pregnancies. METHODS: This was a retrospective cohort study of 188 consecutive MCDA pregnancies treated by bipolar or laser CO, either primarily because of discordant malformation (dMF) or severe selective fetal growth restriction (sFGR), or secondarily when complete bichorionization was not possible in case of twin-to-twin transfusion syndrome (TTTS) or sFGR. Intentional septostomy was performed when needed. The procedure-related PPROM was defined as rupture of membranes <32 weeks' gestation (PROM <32 weeks). Selected pre-, intra-, and early postoperative variables were analyzed by univariate and binomial logistic regression to determine they are correlated to PROM <32 weeks after CO. RESULTS: Between 2006 and 2017, 188 cases underwent CO. Diagnosis was TTTS in 28.2% (n = 53), severe sFGR in 49.5% (n = 93), and dMF in 22.3% (n = 42). PROM <32 weeks occurred in 21.3% (n = 40), resulting in worse perinatal outcomes, as preterm birth <32 weeks occurred in 80.7% (vs. 8.3%, p = 0.000), procedure-to-delivery interval was 47.5 days (vs. 125, p = 0.000), gestational age (GA) at birth 30.0 weeks (vs. 37.7 weeks, p = 0.000), and survival 65.0% (vs. 91.1%, p = 0.000). In univariate analysis, indication, anterior placenta, cervical length, GA at surgery, operation time, amniodistention and drainage fluid volumes, chorioamniotic membrane separation, and septostomy were selected as relevant factors to be included in the regression model. In a multivariate analysis, TTTS was the only factor associated to PROM <32 weeks (OR 3.5 CI 95% 1.5-7.9). CONCLUSIONS: PROM <32 weeks after CO increases the risk of preterm delivery. In this cohort, the membrane rupture was more likely when CO was done in the context of TTTS.
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Transfusão Feto-Fetal , Nascimento Prematuro , Feminino , Transfusão Feto-Fetal/epidemiologia , Transfusão Feto-Fetal/cirurgia , Humanos , Lactente , Recém-Nascido , Gravidez , Gravidez de Gêmeos , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Estudos Retrospectivos , Fatores de Risco , Gêmeos MonozigóticosRESUMO
Kagami-Ogata syndrome (KOS14) is a rare congenital disorder associated with defective genomic imprinting of the chromosome 14q32 domain. Typical features include polyhydramnios, small and bell-shaped thorax, coat-hanger ribs, dysmorphic facial features, abdominal wall defects, placentomegaly, severe postnatal respiratory distress and intellectual disability. To the best of our knowledge, this may be the first case where ultrasound findings such as: severe polyhydramnios, a small bell-shaped thorax, a protuberant abdomen and characteristic dysmorphic face prompted directed family interrogation finally leading to the prenatal diagnosis of KOS14.
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Diagnóstico Pré-Natal , Dissomia Uniparental/diagnóstico , Cromossomos Humanos Par 14/genética , Feminino , Impressão Genômica , Humanos , Deficiência Intelectual/complicações , Masculino , Gravidez , Ultrassonografia Pré-Natal , Dissomia Uniparental/genéticaRESUMO
AIMS: Our aim was to evaluate the long-term effect of cinacalcet in patients with hypercalcaemic secondary hyperparathyroidism (SHPT) after renal transplantation (RT) in order to expand real-world data in this population. METHODS: We performed a multicentre, observational, retrospective study in 17 renal transplant units from Spain. We collected data from renal recipients with hypercalcaemic (calcium >10.2 mg/dL) SHPT (intact parathyroid hormone (iPTH) > 120 pg/mL) who initiated cinacalcet in the clinical practice. RESULTS: We included 193 patients with a mean (standard deviation (SD)) age of 52 (12) years, 58% men. Cinacalcet treatment was initiated at a median of 20 months after RT (median dose 30 mg/day). Mean calcium levels decreased from a mean (SD) of 11.1 (0.6) at baseline to 10.1 (0.8) at 6 months (9.0% reduction, P < 0.0001). Median iPTH was reduced by 23.0% at 6 months (P = 0.0005) and mean phosphorus levels increased by 11.1% (P < 0.0001). The effects were maintained up to 3-years. No changes were observed in renal function or anticalcineurin drug levels. Only 4.1% of patients discontinued cinacalcet due to intolerance and 1.0% due to lack of efficacy. CONCLUSIONS: In renal transplant patients with hypercalcaemic SHPT, cinacalcet controlled serum calcium, iPTH and phosphorus levels up to 3 years. Tolerability was good.
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Hipercalcemia/tratamento farmacológico , Hiperparatireoidismo Secundário/tratamento farmacológico , Transplante de Rim/efeitos adversos , Naftalenos/uso terapêutico , Adulto , Idoso , Cálcio/sangue , Cinacalcete , Feminino , Humanos , Hipercalcemia/sangue , Hiperparatireoidismo Secundário/sangue , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Fósforo/sangue , Estudos RetrospectivosRESUMO
Non-melanoma skin cancer (NMSC) is the most frequent malignancy in organ transplant recipients. The aetiology of NMSC after transplant is multifactorial. The aim of this study was to determine the clinical and environmental factors involved in the development of NMSC in a Spanish kidney transplant population from the Mediterranean region. A total of 289 patients who had received a kidney transplant during the period January 1996 to December 2010 were included in the study. Both prospective and retrospective data were used. All patients underwent a structured interview and a complete examination of the skin. After a median follow-up of 72 months (range 12-180 months), 73 of the 289 patients (25.2%) developed 162 tumours. The ratio of basal cell carcinoma to squamous cell carcinoma was 2.21:1. The cumulative incidence of NMSC increased with the duration of immunosuppression, from 20.78% at 5 years, to 37.35% at 10 years to 53.08% at 15 years after transplantation. Age at the time of transplant, phototype and occupational sun exposure were associated with a higher risk of NMSC. NMSC is a significant clinical problem in kidney transplant recipients. This has implications for the development of prevention and surveillance strategies. Clinical and environmental factors may be used to identify those patients who are at risk for NMSC.
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Carcinoma Basocelular/epidemiologia , Carcinoma de Células Escamosas/epidemiologia , Transplante de Rim/efeitos adversos , Neoplasias Cutâneas/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Biópsia , Carcinoma Basocelular/patologia , Carcinoma de Células Escamosas/patologia , Feminino , Humanos , Imunossupressores/efeitos adversos , Incidência , Estimativa de Kaplan-Meier , Masculino , Região do Mediterrâneo , Pessoa de Meia-Idade , Análise Multivariada , Exposição Ocupacional/efeitos adversos , Lesões Pré-Cancerosas/epidemiologia , Modelos de Riscos Proporcionais , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Neoplasias Cutâneas/patologia , Espanha/epidemiologia , Luz Solar/efeitos adversos , Inquéritos e Questionários , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: The aim of this study is to evaluate the independent and combined value of gestational age, fetal weight, fetoplacental Doppler, and myocardial performance index for the prediction of individual risk of early (≤7 days) intrauterine fetal death (IUFD) after laser therapy in twin-to-twin transfusion syndrome (TTTS). MATERIAL AND METHODS: A consecutive series of 215 cases of TTTS treated with laser therapy in three centers was prospectively studied. Ultrasound evaluation within 24 h of surgery included estimated fetal weight discordance, umbilical artery, pulsatility index (PI) and diastolic flow evaluation, middle cerebral artery PI and middle cerebral artery peak systolic velocity, ductus venosus PI and atrial flow assessment, and modified myocardial performance index. Logistic regression analysis was used to explore the association of preoperative parameters with IUFD. RESULTS: Intrauterine fetal death occurred in 17 (7.9%) of the recipients and 33 (15.3%) donors (p = 0.016). The only independent predictors of IUFD in recipients was the middle cerebral artery peak systolic velocity >1.5 MoM (OR = 22, p = 0.015), but this event was present in only 3% of recipients. In donors, reverse end diastolic flow in the umbilical artery (OR = 14.748, p = 0.033), estimated fetal weight discordance (OR = 1.054, p = 0.036), and gestational age (OR = 0.757, p = 0.046) were independent predictors. CONCLUSION: In TTTS, preoperative fetal assessment can identify independent risk factors for early post-operative IUFD, particularly in donors.
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Morte Fetal/diagnóstico , Morte Fetal/etiologia , Transfusão Feto-Fetal/mortalidade , Transfusão Feto-Fetal/cirurgia , Fetoscopia/mortalidade , Terapia a Laser/mortalidade , Feminino , Morte Fetal/epidemiologia , Peso Fetal , Transfusão Feto-Fetal/diagnóstico , Idade Gestacional , Humanos , Individualidade , Gravidez , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Gêmeos Monozigóticos , Ultrassonografia Doppler , Ultrassonografia Pré-NatalRESUMO
Previous reports suggest that cord blood biomarkers could serve as a prognostic tool for conotruncal congenital heart defects (CHD). We aimed to describe the cord blood profile of different cardiovascular biomarkers in a prospective series of fetuses with tetralogy of Fallot (ToF) and D-transposition of great arteries (D-TGA) and to explore their correlation with fetal echocardiography and perinatal outcome. Methods: A prospective cohort study (2014-2019), including fetuses with isolated ToF and D-TGA and healthy controls, was conducted at two tertiary referral centers for CHD in Barcelona. Obstetric ultrasound and fetal echocardiography were performed in the third trimester and cord blood was obtained at delivery. Cord blood concentrations of N-terminal precursor of B-type natriuretic peptide, Troponin I, transforming growth factorß (TGFß), placental growth factor, and soluble fms-like tyrosine kinase-1 were determined. Results: Thirty-four fetuses with conotruncal-CHD (22 ToF and 12 D-TGA) and 36 controls were included. ToF-fetuses showed markedly increased cord blood TGFß (24.9â ng/ml (15.6-45.3) vs. normal heart 15.7â ng/ml (7.2-24.3) vs. D-TGA 12.6â ng/ml (8.7-37.9); P = 0.012). These results remained statistically significant even after adjusting for maternal body mass index, birth weight and mode of delivery. TGFß levels showed a negative correlation with the pulmonary valve diameter z-score at fetal echocardiography (r = -0.576, P = 0.039). No other differences were found in the rest of cord blood biomarkers among the study populations. Likewise, no other significant correlations were identified between cardiovascular biomarkers, fetal echocardiography and perinatal outcome. Conclusions: This study newly describes increased cord blood TGFß concentrations in ToF compared to D-TGA and normal fetuses. We also demonstrate that TGFß levels correlate with the severity of right ventricle outflow obstruction. These novel findings open a window of research opportunities on new prognostic and potential preventive strategies.
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OBJECTIVE: To compare the outcomes of twin-to-twin transfusion syndrome (TTTS) cases treated with fetoscopic laser coagulation of vascular anastomoses before 25 + 6 weeks of gestation and between 26 and 28 weeks of gestation. MATERIAL AND METHODS: 28 consecutive cases of TTTS at Quintero stages II-IV treated with laser therapy between 26 + 0 and 28 + 6 weeks of gestation were compared with 324 cases treated between 15 + 0 and 25 + 6 weeks during a 3-year period in two centers. The following data were recorded and compared: duration of the fetoscopy, rate of complications (preterm labor before 28 weeks and before 32 weeks, chorioamnionitis, twin anemia-polycythemia syndrome and recurrent TTTS), gestational age at delivery and neonatal survival rate. RESULTS: The study groups were similar as regards Quintero staging and the frequency of anterior placental location (50.0 vs. 47.8%, p = 0.85 in late and conventional laser, respectively). There were no significant differences in the duration of surgery (29 vs. 30, p = 0.27, respectively) and in the rates of any of the complications evaluated. Gestational age at delivery (33 vs. 33.3 weeks, p = 0.69) and neonatal survival of at least one fetus (92.3 vs. 88.6%, p = 0.24) were also similar. CONCLUSION: Fetoscopic laser coagulation for TTTS performed between 26 + 0 and 28 + 6 weeks of gestation was associated with similar outcomes as those observed in cases treated before 26 weeks.
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Transfusão Feto-Fetal/cirurgia , Fetoscopia , Fotocoagulação a Laser , Feminino , Idade Gestacional , Humanos , Gravidez , Segundo Trimestre da Gravidez , Terceiro Trimestre da Gravidez , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate pre- and postoperative predictors of preterm birth in twin-to-twin transfusion syndrome treated with fetoscopic placental laser coagulation. STUDY DESIGN: Prospective cohort study (n = 166) assessing cervical length (pre and postoperatively), amniotic fluid interleukin-6, serum C-reactive protein and duration of surgery. Logistic regression was used to investigate associations with preterm delivery. RESULTS: Preterm delivery within 7 days, before 28.0 and 32.0 weeks occurred in 4.8%, 16.8%, and 28.9%, respectively. The only significant predictor of delivery within 7 days was postoperative cervical length (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3-0.9). Concerning delivery before 32.0 weeks, preoperative cervical length (OR, 0.9; 95% CI, 0.8-1.0), and gestational age (OR, 0.8; 95% CI, 0.4-0.9) were independent risk factors but the association was weak. The presence of a single survivor after surgery was associated with a clear reduction of risk (OR, 0.3; 95% CI, 0.1-0.6). Inflammatory biomarkers and duration of surgery did not discriminate risk of prematurity. CONCLUSION: No strong preoperative predictive factor of preterm birth could be identified. A single survivor was a strong protective factor of very preterm birth.
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Líquido Amniótico/química , Proteína C-Reativa/análise , Fetoscopia/efeitos adversos , Interleucina-6/análise , Nascimento Prematuro/diagnóstico , Adulto , Biomarcadores/análise , Medida do Comprimento Cervical/métodos , Feminino , Transfusão Feto-Fetal/metabolismo , Transfusão Feto-Fetal/cirurgia , Fetoscopia/métodos , Humanos , Recém-Nascido , Fotocoagulação a Laser/métodos , Modelos Logísticos , Gravidez , Nascimento Prematuro/sangue , Nascimento Prematuro/etiologia , Estudos Prospectivos , Fatores de RiscoRESUMO
BACKGROUND: Cervical varices complicating pregnancy are rare but can cause significant maternal and perinatal morbidity. There is limited evidence regarding the optimal management of bleeding caused by cervical varices during pregnancy. CASE: A 38-year-old woman was admitted to the hospital at 16 weeks of gestation due to vaginal hemorrhage in the setting of cervical varices accompanied by placenta previa. A cervical pessary was placed at 21 weeks of gestation without further bleeding. Magnetic resonance imaging demonstrated variceal reduction after pessary placement, and a cesarean delivery was performed at 36 weeks of gestation without complications. CONCLUSION: Cervical pessary should be considered as conservative option to control the bleeding associated with cervical varices during pregnancy.
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Colo do Útero/irrigação sanguínea , Complicações Hematológicas na Gravidez/diagnóstico , Diagnóstico Pré-Natal , Hemorragia Uterina/diagnóstico , Varizes/diagnóstico , Adulto , Diagnóstico Diferencial , Feminino , Humanos , Pessários , Gravidez , Complicações Hematológicas na Gravidez/terapia , Segundo Trimestre da Gravidez , Hemorragia Uterina/terapia , Varizes/terapiaRESUMO
BACKGROUND AND OBJECTIVES: The relationship between mineral metabolism disorders, bone fractures and vascular calcifications in kidney transplant recipients has not been established. METHOD: We performed a cross-sectional study in 727 stable recipients from 28 Spanish transplant clinics. Mineral metabolism parameters, the semi-quantification of vertebral fractures and abdominal aortic calcifications were determined centrally. RESULTS: Vitamin D deficiency (25OHD3<15ng/ml) was more common in female recipients at CKD-T stages I-III (29.6% vs 44.4%; p=0.003). The inverse and significant correlation between 25OHD3 and PTH was gender-specific and women exhibited a steeper slope than men (p=0.01). Vertebral fractures (VFx) with deformity grade ≥2 were observed in 15% of recipients. Factors related to VFx differed by gender; in males, age (OR 1.04; 95% CI 1.01-1.06) and CsA treatment (OR: 3.2; 95% CI: 1.6-6.3); in females, age (OR 1.07; 95% CI: 1.03-1.12) and PTH levels (OR per 100pg/ml increase: 1.27; 95% CI: 1.043-1.542). Abdominal aortic calcifications were common (67.2%) and related to classical risk factors but not to mineral metabolism parameters. CONCLUSIONS: Vitamin D deficiency is more common among female kidney transplant recipients at earlier CKD-T stages, and it contributes to secondary hyperparathyroidism. Prevalent vertebral fractures are only related to high serum PTH levels in female recipients.
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Doenças da Aorta/metabolismo , Calcinose/metabolismo , Transplante de Rim , Minerais/metabolismo , Complicações Pós-Operatórias/metabolismo , Fatores Sexuais , Fraturas da Coluna Vertebral/metabolismo , Idoso , Albuminúria/etiologia , Aorta Abdominal , Doenças da Aorta/etiologia , Calcinose/etiologia , Estudos Transversais , Ciclosporina/efeitos adversos , Feminino , Humanos , Hiperparatireoidismo Secundário/etiologia , Hiperparatireoidismo Secundário/metabolismo , Imunossupressores/efeitos adversos , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Fatores de Risco , Fraturas da Coluna Vertebral/etiologia , Tacrolimo/efeitos adversos , Deficiência de Vitamina D/complicaçõesRESUMO
This study evaluated health-related quality of life (HRQOL) in a Spanish sample of chronic kidney disease patients (n = 90) undergoing different renal replacement therapies, considering the influence of treatment stressors, mood, anxiety and quality of sleep. While all patients had worse physical functioning than controls (p < .01), only those undergoing haemodialysis (HD) showed worse physical well-being, occupational functioning, spiritual fulfillment and more health interference with work (p < .05). They also obtained higher depression scores than renal transplant patients (TX) (p = .005). Those TX receiving the immunosuppressor sirolimus exhibited more cardiac/renal, cognitive and physical limitations than the rest (p < .05). Dialysis vintage correlated positively with sleep disturbances and depression scores and negatively with total Quality of Life (QLI) (p < .05). HD patients experienced more psychological distress than peritoneal dialysis patients (PD) (p = .036). Regression models including sleep, anxiety and depression were estimated for subscales of HRQOL. In TX patients, low depressive scores related to an optimal QLI in almost all subscales, while in HD patients they explained part of the variability in psychological well-being, interpersonal functioning and personal fulfillment. HD condition results in a QLI more distant to the standards of controls.
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Qualidade de Vida/psicologia , Insuficiência Renal Crônica/psicologia , Terapia de Substituição Renal/psicologia , Estresse Psicológico/psicologia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/terapia , Adulto JovemRESUMO
BACKGROUND AND OBJECTIVES: In the present study, clinical criteria used by Spanish nephrologists when approaching chronic kidney disease (CKD) in kidney recipients, as well as their level of maintenance and control of renal function, were evaluated. METHODS: An epidemiological, observational, multicenter, nation-wide, prospective study was carried out, with a 6-month follow-up period. Three hundred and sixty-eight adult patients with stage3 kidney disease after a 24-month or longer post-transplantation follow-up period were included. Visits schedule included a retrospective visit, a baseline visit, an optional mid-term visit, and a final visit at month6. RESULTS: Mean time since kidney transplantation was 8.2±5.4years. Most common pre-transplant cardiovascular risk factors were high blood pressure (80.2%), followed by high cholesterol levels (61.7%). Serum creatinine levels showed a statistically significant decrease from baseline visit to 6-month visit (0.06±0.22; P<.0001), and glomerular filtration rate (GFR) reduction was -1.03±6.14 (P=0.0014). Significant independent prognostic factors for GFR worsening were: higher 24-hour proteinuria (OR=1.001 per mg; P=.020), longer time since transplantation (OR=1.009 per month; P=.017), and lower hemoglobin levels (OR=1.261 per g/dl; P=.038). Donor age also had some negative influence (OR=1.021 per year; P=.106). Biopsies were obtained in only 8% of kidney transplant recipients with stage 3 CKD with an intervention being carried out in 25.4% of cases. CONCLUSIONS: Secondary markers and factors resulting in CKD progression, particularly anemia, are still frequently uncontrolled after kidney transplantation. Only about 2% of patients benefit from a therapeutic intervention based on a biopsy. Clinical perception differs from objective measures, which results in an obvious clinical inertia regarding risk factor control in such patients.
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Nefropatias/terapia , Transplante de Rim , Complicações Pós-Operatórias/terapia , Adulto , Idoso , Atitude do Pessoal de Saúde , Biópsia/estatística & dados numéricos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Comorbidade , Gerenciamento Clínico , Progressão da Doença , Feminino , Seguimentos , Humanos , Imunossupressores/uso terapêutico , Rim/patologia , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Médicos/psicologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Reoperação , Fatores de Risco , Espanha/epidemiologiaRESUMO
BACKGROUND: The effect of cinacalcet in patients with persistent secondary hyperparathyroidism (SHPT) after kidney transplantation (RT) has mainly been reported in patients with secondary hypercalcaemia. OBJECTIVES: Our objective was to assess the long-term effect of cinacalcet on patients with a RT and normocalcaemic SHPT. METHODS: A one-year multicentre, observational, retrospective study that included kidney recipients with SHPT (intact parathyroid hormone [iPTH] >120 pg/ml) and calcium levels within the normal range (8.4-10.2 mg/dl). Patients began treatment with cinacalcet in clinical practice. RESULTS: 32 patients with a mean age (standard deviation [SD]) of 54 (11) years, 56% male, were included in the study. Treatment with cinacalcet began a median of 16 months after RT (median dose of 30 mg/day). Levels of iPTH decreased from a median (P25, P75) of 364 (220, 531) pg/ml at the start of the study to 187 (98, 320) after 6 months (48.6% reduction, P=.001) and to 145 (91, 195) after 12 months (60.2% reduction, P=.001), without there being changes in calcium and phosphorus levels (P=.214 and P=.216, respectively). No changes were observed in kidney function or anti-calcineuric drug levels. 3.1% of patients discontinued cinacalcet due to intolerance and 6.2% due to a lack of efficacy. CONCLUSIONS: In patients with normocalcaemic SHPT after RT, cinacalcet improves the control of serum PTH values without causing changes to calcaemia, phosphataemia or kidney function. Cinacalcet showed good tolerability.
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Hiperparatireoidismo Secundário/tratamento farmacológico , Transplante de Rim , Naftalenos/uso terapêutico , Complicações Pós-Operatórias/tratamento farmacológico , Cinacalcete , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoRESUMO
Some renal transplant patients show cognitive, emotional, and behavioral changes as part of possible neurotoxic effects associated with immunosuppressive medication, especially tacrolimus. This study evaluated effects of immunosuppressive drugs on some cognitive tasks. Patients treated with sirolimus and cyclosporine reported some of the noncognitive side effects related to immunosuppressive treatment. We observed attention and working memory impairment in patients treated with sirolimus or tacrolimus. Performance of cyclosporine-treated subjects was similar to that of healthy volunteer controls. Since the mood, anxiety, and sleep patterns measured were unaffected, it could be concluded that the cognitive deficit found was partly related to treatment.
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Transtornos Cognitivos/induzido quimicamente , Transtornos Cognitivos/psicologia , Rejeição de Enxerto/tratamento farmacológico , Imunossupressores/efeitos adversos , Adulto , Análise de Variância , Transtornos Cognitivos/patologia , Feminino , Seguimentos , Rejeição de Enxerto/psicologia , Humanos , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Projetos Piloto , Escalas de Graduação Psiquiátrica , Qualidade de Vida , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/etiologia , Inquéritos e Questionários , Adulto JovemRESUMO
Background. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) decrease cardiovascular mortality and slow the progression of renal disease in non-transplant patients, but their impact on kidney transplant outcome has not been well established.Methods. Patients receiving a renal allograft in Spain in 1990, 1994, 1998 and 2002 were considered for the present study. Only adult (>/=18 years) recipients of a single kidney transplant functioning at the end of the first year were considered. A total of 4842 patients with clinical data about ACEI/ARB therapy were included.Results. During the initial 2 years after transplant, ACEI/ARB were less frequently used in the 1990 and 1994 cohorts than in 1998 and 2002 (15.1%, 24.6%, 33.5% and 45.1%, respectively; P < 0.001). During the first year, a total of 1063 patients (22.8%) received ACEI/ARB treatment, and graft survival (50.0% for treated patients and 51.4% for untreated, P = ns), death-censored graft survival (60.6% versus 63.5%, P = ns) and patient survival (68.8% versus 66.6%, P = ns) were not different. During the initial 2 years, 1472 patients (31.4%) received treatment with ACEI/ARB, and graft survival tended to be higher in treated patients (54.4% and 50.9%, P = 0.063). Since there was an interaction between ACEI/ARB treatment and year of transplant, graft survival was analysed in each cohort. Cox regression analysis including the propensity score for ACEI/ARB treatment showed an association between ACEI/ARB treatment and graft survival in the 2002 cohort (relative risk 0.36 and 95% confidence interval 0.17-0.75, P = 0.007). Death-censored graft survival (63.8% versus 63.1%, P = ns) and patient survival (68.1% and 66.5%, P = ns) were not significantly different.Conclusions. The use of ACEI/ARB during the initial 2 years after transplantation was associated with a better graft survival, but this effect was only observed in the 2002 cohort.