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BACKGROUND: Hospital readmission (HR) after surgery is considered a quality metric. METHODS: Data on 2371 first-time adult kidney transplant (KT) recipients were collected to analyze the "early" (≤30 days) and "late" (31-365 days) HR patterns after KT at a single center over a 12-year time span (2002-2013). RESULTS: 30-day, 90-day, and 1-year HR were 31%, 41%, and 53%, respectively. Risk factors for HR included age >50, female sex, black race, BMI >30, transplant LOS >5 days, and pre-transplant time on dialysis >765 days. Indications for early (n = 749) and late (n = 508) HR were similar. Early HR (OR: 3.80, P = .007) and black race (OR: 2.38, P = .009) were associated with higher odds of 1-year graft failure while frequency (1-2, 3-4, 5+) of HR (ORs: 4.68, 8.36, 9.44, P < .001) and age > 50 (OR: 2.11, P = .007) were associated with higher odds of 1-year mortality. Transplant LOS > 5 days increased both odds of 1-year graft failure (OR: 3.51, P = .001) and mortality (OR: 2.05, P = .006). One-year graft and recipient survival were 96.7% and 94.8%, respectively. CONCLUSIONS: Hospital readmission was associated with reduced graft and patient survival; however, despite a relatively high and consistent HR rate after KT, overall 1-year graft and patient survival was high.
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Transplante de Rim , Adulto , Feminino , Sobrevivência de Enxerto , Humanos , Readmissão do Paciente , Diálise Renal , Fatores de Risco , TransplantadosRESUMO
The organs-on-a-chip technology has shown strong promise in mimicking the complexity of native tissues in vitro and ex vivo, and recently significant advances have been made in applying this technology to studies of the kidney and its diseases. Individual components of the nephron, including the glomerulus, proximal tubule, and distal tubule/medullary collecting duct, have been successfully mimicked using organs-on-a-chip technology and yielding strong promises in advancing the field of ex vivo drug toxicity testing and augmenting renal replacement therapies. Although these models show promise over 2-dimensional cell systems in recapitulating important nephron features in vitro, nephron functions, such as tubular secretion, intracellular metabolism, and renin and vitamin D production, as well as prostaglandin synthesis are still poorly recapitulated in on-chip models. Moreover, construction of multiple-renal-components-on-a-chip models, in which various structures and cells of the renal system interact with each other, has remained a challenge. Overall, on-chip models show promise in advancing models of normal and pathological renal physiology, in predicting nephrotoxicity, and in advancing treatment of chronic kidney diseases.
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Reatores Biológicos , Desenvolvimento de Medicamentos/instrumentação , Nefropatias/terapia , Rim/efeitos dos fármacos , Dispositivos Lab-On-A-Chip , Procedimentos Analíticos em Microchip , Terapia de Substituição Renal , Testes de Toxicidade/instrumentação , Animais , Desenvolvimento de Medicamentos/métodos , Desenho de Equipamento , Humanos , Rim/fisiopatologia , Nefropatias/induzido quimicamente , Nefropatias/diagnóstico , Nefropatias/fisiopatologia , Testes de Toxicidade/métodosRESUMO
INTRODUCTION: Orthotopic liver transplantation (OLT) can be associated with significant bleeding requiring multiple blood product transfusions. Rotational thromboelastometry (ROTEM) is a point-of-care device that has been used to monitor coagulation during OLT. Whether it reduces blood loss/transfusions during OLT remains controversial. MATERIALS AND METHODS: We aim to compare ROTEM with conventional coagulation tests (aPTT, PT, INR, platelet count, fibrinogen) to guide transfusion of platelets, cryoprecipitate, and fresh frozen plasma (FFP) during OLT over 3 years. Thirty-four patients who had transfusions guided by ROTEM were compared to 34 controls who received transfusions guided by conventional coagulation tests (CCT). Intraoperative blood loss, type/ amount of blood products transfused, and direct costs were compared between the two groups. RESULTS: The ROTEM group had significantly less intra-operative blood loss (2.0 vs. 3.0 L, p = 0.04) and fresh frozen plasma (FFP) transfusion (4 units vs. 6.5 units, p = 0.015) compared to the CCT group (2.0L vs. 3.0L, p = 0.04). However, total number of patients transfused cryoprecipitate was increased in ROTEM (n = 25;73%) as compared to CCT (n = 19; 56%), p = 0.033. The direct cost of blood products plus testing was reduced in the ROTEM group ($113,142.89 vs. $127,814.77). CONCLUSION: In conclusion implementation of a ROTEM-guided transfusion algorithm resulted in a reduction in intra-operative blood loss, FFP transfusion and a decrease in direct cost during OLT. ROTEM is a useful and safe point of care device in OLT setting.
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Testes de Coagulação Sanguínea/economia , Coagulação Sanguínea , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/economia , Custos Hospitalares , Transplante de Fígado/economia , Monitorização Intraoperatória/economia , Tromboelastografia/economia , Algoritmos , Análise Custo-Benefício , Procedimentos Clínicos/economia , Feminino , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: De novo donor-specific antibodies (dnDSA) post-transplant correlate with a higher risk of immunologic graft injury and loss following kidney and pancreas transplantation. Post-transplant dnDSA can occur within the first post-transplant year. METHODS: In this study, 817 of 1290 kidney and simultaneous kidney/pancreas recipients were tested for dnDSA post-transplant. Recipient immunosuppressive treatment at one, three, six, and 12 months post-transplant was correlated with dnDSA incidence by univariate and multivariate analyses. RESULTS: The overall incidence of dnDSA was 21.3% detected a median of 3.5 yr post-transplant. By univariate analysis, the immunosuppressive treatment at all time points correlated with dnDSA (p < 0.01). Month 6 treatment correlated best in multivariable analysis (p = 0.004). At six months, recipients receiving rapamune/mycophenolic acid (Rapa/MPA) had the highest dnDSA incidence at five yr (25.3%) and last follow-up (30.7%), those treated with cyclosporine/rapamune (CNI/Rapa) had the lowest incidence at five yr (10.8%) and last follow-up (18.6%), and cyclosporine/mycophenolic acid (CNI/MPA) treatment had an intermediate incidence at five yr (16.7%) and last follow-up (20.4%) (p < 0.01). Six-month CNI/MPA and Rapa/MPA treatment significantly correlated with dnDSA (hazard ratios of 2.36 and 1.80, respectively) by Cox proportional hazards regression modeling. CONCLUSION: The risk of post-transplant dnDSA development correlates with early immunosuppressive management.
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Rejeição de Enxerto/imunologia , Sobrevivência de Enxerto/imunologia , Imunossupressores/uso terapêutico , Isoanticorpos/imunologia , Transplante de Rim/efeitos adversos , Transplante de Pâncreas/efeitos adversos , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Seguimentos , Rejeição de Enxerto/sangue , Rejeição de Enxerto/diagnóstico , Humanos , Isoanticorpos/sangue , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Prognóstico , Fatores de Risco , Doadores de Tecidos , Adulto JovemRESUMO
The natural vitamin E family is composed of 8 members equally divided into 2 classes: tocopherols (TCP) and tocotrienols (TE). A growing body of evidence suggests TE possess potent biological activity not shared by TCP. The primary objective of this work was to determine the concentrations of TE (200 mg mixed TE, b.i.d.) and TCP [200 mg α-TCP, b.i.d.)] in vital tissues and organs of adults receiving oral supplementation. Eighty participants were studied. Skin and blood vitamin E concentrations were determined from healthy participants following 12 wk of oral supplementation of TE or TCP. Vital organ vitamin E levels were determined by HPLC in adipose, brain, cardiac muscle, and liver of surgical patients following oral TE or TCP supplementation (mean duration, 20 wk; range, 1-96 wk). Oral supplementation of TE significantly increased the TE tissue concentrations in blood, skin, adipose, brain, cardiac muscle, and liver over time. α-TE was delivered to human brain at a concentration reported to be neuroprotective in experimental models of stroke. In prospective liver transplantation patients, oral TE lowered the model for end-stage liver disease (MELD) score in 50% of patients supplemented, whereas only 20% of TCP-supplemented patients demonstrated a reduction in MELD score. This work provides, to our knowledge, the first evidence demonstrating that orally supplemented TE are transported to vital organs of adult humans. The findings of this study, in the context of the current literature, lay the foundation for Phase II clinical trials testing the efficacy of TE against stroke and end-stage liver disease in humans.
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Doença Hepática Terminal/dietoterapia , Tocotrienóis/administração & dosagem , Tocotrienóis/farmacocinética , Adulto , Transporte Biológico Ativo , Suplementos Nutricionais , Progressão da Doença , Doença Hepática Terminal/metabolismo , Doença Hepática Terminal/prevenção & controle , Feminino , Humanos , Transplante de Fígado , Masculino , Estudos Prospectivos , Distribuição Tecidual , Tocoferóis/administração & dosagem , Tocoferóis/farmacocinética , Vitamina E/metabolismoRESUMO
Patients with glycogen storage diseases pose unique management challenges to clinicians.These challenges are exacerbated wheneverthey undergo surgery as the basic anomaly in their glycogen storage pathways make them susceptible to organic acidosis, which may in turn complicate their preoperative, intraoperative, and postoperative course. Because of the rarity of these diseases, clinicians may not be aware of the specific management concerns. In the case reported here, a 37-year-old patient with glycogen storage disease type 1 underwentleft hepatectomy for hepatic adenomatosis, which was complicated by intraoperative severe lactic acidosis that was successfully treated. After successful hepatectomy, the patient underwent liver transplant without major lactic acidosis or hemodynamic instability. Early recognition and aggressive management of blood sugar and lactic acidosis in patients with glycogen storage diseases can allow for successful outcomes even when complex surgical procedures are required.
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Acidose Láctica , Doença de Depósito de Glicogênio , Adulto , Doença de Depósito de Glicogênio/diagnóstico , Doença de Depósito de Glicogênio/cirurgia , Hepatectomia , Humanos , Fígado , Resultado do TratamentoRESUMO
OBJECTIVES: Large spontaneous splenorenal shunts can result in portal vein steal syndrome and is a risk factor for portal vein thrombosis after orthotopic liver transplant. Disconnection of these shunts by left renal vein ligation has been suggested as a potential technique for improving portal venous flow and mitigating risk of portal vein thrombus, thus improving graft perfusion. We present a series of 6 patients who underwent left renal vein ligation for spontaneous splenorenal shunts and their outcomes. MATERIALS AND METHODS: This retrospective analysis included all orthotopic liver transplant recipients who underwent left renal vein ligation for spontaneous splenorenal shunts between 2016 and 2017. Portal venous flow, patency, and renal function were assessed postoperatively. Liver Doppler ultrasonography scans were obtained 1, 3, and 5 days postligation, and serum creatinine was evaluated at 1 and 2 weeks and 1, 3, 6, and 12 months postligation. RESULTS: Over the 1-year study period, 92 orthotopic liver transplants were performed. In 6 patients who underwent left renal vein ligation, spontaneous splenorenal shunts were identified preoperatively. One patient received a retransplant complicated by portal vein thrombus and underwent thrombectomy with left renal vein ligation. Concurrent left renal vein ligation and liver transplant were performed in 5 patients, 2 with known portal vein thrombus at the time of transplant requiring thrombectomy. All patients had subjective intraoperative improvements in portal venous flow after ligation. Zero patients developed postoperative portal vein thrombus. No patients developed clinically significant renal dysfunction at 1-year follow-up. CONCLUSIONS: Left renal vein ligation is technically feasible, has minimal and transient effects on renal function, and can improve portal venous flow, thus mitigating the risk for portal vein thrombus, graft hypoperfusion, and possible dysfunction.
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Transplante de Fígado , Veias Renais , Derivação Esplenorrenal Cirúrgica , Trombose , Humanos , Transplante de Fígado/efeitos adversos , Veias Renais/diagnóstico por imagem , Veias Renais/cirurgia , Estudos Retrospectivos , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/prevenção & controle , Resultado do TratamentoRESUMO
Organ-on-a-chip platforms have recently seen tremendous progress. They have found potential applications in the study of physiology and pathology of tissues, drug toxicity, and development of tissue models for replacement of animal studies. However, their potential role in organ transplantation has hardly been discussed, so far. Organ transplantation represents a major medical advancement of the twenty-first century, yet it suffers from limitation due to the shortage of organ supply. Very often, organs harvested from donor's body are deemed non-usable because of being damaged or "marginal". Recently, developments of bioartificial devices such as artificial placenta and renal assist-devices have shown that it is possible to develop novel bioartificial organ support systems that can support the healing of damaged or marginal organs prior to their transplantation. In the current article, we introduce a novel concept for building bioartificial organ assist devices and systems by integrating arrays of numerous organ-on-a-chip platforms. The new system can be used in organ repair centers as means for temporary organ support and functional enhancement. We have also briefly reviewed the relevant organ-on-a-chip platforms developed so far, and related literature to form a basis for developing our new concept, device and its application. The proposed system may help to increase the number of organs available for transplantation and improve transplantation outcomes. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 2006-2018, 2019.
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Órgãos Artificiais , Dispositivos Lab-On-A-Chip , Modelos Biológicos , Animais , HumanosRESUMO
BACKGROUND: Steroid-free immunosuppression is an attractive option because it avoids the many side effects of chronic corticosteroid use. It is especially attractive in pancreas recipients because it avoids the diabetogenic effects of steroids. METHODS: We evaluated the outcome of a steroid-free maintenance immunosuppressive protocol in pancreas transplant recipients. Between August 2003 and May 2006, a total of 97 pancreas transplant recipients received steroid-free maintenance immunosuppression, consisting of induction with thymoglobulin and prednisone for the first 5 days. Patients were maintained on sirolimus adjusted to a target rapamycin trough level and reduced-dose cyclosporine adjusted to target C2 levels. All pancreas transplants (n=124) performed in the previous 3 years and maintained on a steroid-based immunosuppressive protocol with cyclosporine and mycophenolate mofetil were used for comparison. RESULTS: One-year patient and death censored pancreas graft survival were 93.8% and 94.8% for the steroid free group versus 95.2% and 87.9% for the comparator group, respectively. The incidence of acute rejection was 9.3% in the steroid-free group versus 28.3% in the comparator group (P<0.01). No pancreas loss in the steroid-free group was caused by acute rejection, whereas seven (5.6%) patients in the comparator group lost their pancreases because of acute rejection (P<0.05). At 1 year after transplant, the mean serum glucose and creatinine levels were not different between the two groups. CONCLUSION: We conclude that excellent graft survival with a significantly lower incidence of acute rejection can be achieved using a steroid-free maintenance immunosuppressive protocol consisting of sirolimus and cyclosporine.
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Ciclosporina/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Terapia de Imunossupressão/métodos , Imunossupressores/uso terapêutico , Transplante de Pâncreas/imunologia , Sirolimo/uso terapêutico , Corticosteroides , Sobrevivência de Enxerto/efeitos dos fármacos , Humanos , Imunossupressores/farmacocinética , Contagem de Leucócitos , Lipídeos/sangue , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Resultado do TratamentoRESUMO
AIM: To study mortality, length of stay, and total charges in morbidly obese adults during index hospitalization for orthotopic liver transplantation. METHODS: The Nationwide Inpatient Sample was queried to obtain demographics, healthcare utilization, post orthotopic liver transplantation (OLT) complications, and short term outcomes of OLT performed from 2003 to 2011 (n = 46509). We divided patients into those with [body mass index (BMI) ≥ 40] and without (BMI < 40) morbid obesity. Multivariable logistic regression analysis was performed to characterize differences in in-hospital mortality, length of stay (LOS), and charges for OLT between patients with and without morbid obesity after adjusting for significant confounders. Additionally, propensity matching was performed to further validate the results. RESULTS: Of the 46509 patients who underwent OLT during the study period, 818 (1.8%) were morbidly obese. Morbidly obese recipients were more likely to be female (46.8% vs 33.4%, P = 0.002), Caucasian (75.2% vs 67.8%, P = 0.002), in the low national income quartile (32.3% vs 22.5%, P = 0.04), and have ≥ 3 comorbidities (modified Elixhauser index; 83.9% vs 45.0%, P < 0.001). Morbidly obese patient also had an increase in procedure related hemorrhage (P = 0.028) and respiratory complications (P = 0.043). Multivariate and propensity matched analysis showed no difference in mortality (OR: 0.70; 95%CI: 0.27-1.84, P = 0.47), LOS (ß: -4.44; 95%CI: -9.93, 1.05, P = 0.11) and charges for transplantation (ß: $15693; 95%CI: -51622-83008, P = 0.64) between the two groups. Morbidly obese patients were more likely to have transplants on weekdays (81.7%) as compared to those without morbid obesity (75.4%, P = 0.029). CONCLUSION: Morbid obesity may not impact in-hospital mortality and health care utilization in OLT recipients. However, morbidly obese patients may be selected after careful assessment of co-morbidities.
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BACKGROUND: This 36-month, randomized, parallel-group study compared safety and efficacy of two doses of everolimus with mycophenolate mofetil (MMF) in de novo renal-transplant recipients. METHODS: Renal-allograft recipients received 1.5 mg/day or 3 mg/day of everolimus or 2 g/day of MMF, plus full-dose cyclosporine (CsA) and corticosteroids after randomization. For at least their first year, patients received study medication according to a double-blinded, double-dummy design. Concerns over nephrotoxicity led to a protocol amendment to an open-label design with reduced CsA troughs. RESULTS: Incidences of primary efficacy failure at 36 months (biopsy-proven acute rejection, graft loss, death, or loss to follow-up) were everolimus 1.5 mg/day, 33.7% (65/193); everolimus 3 mg/day, 34.0% (66/194); and MMF, 31.1% (61/196) (P=0.810). Antibody-treated acute rejection at 36 months was significantly lower with everolimus 1.5 mg (9.8%) than MMF (18.4%, P=0.014). Discontinuation for adverse events was more frequent with everolimus and hemolytic uremic syndrome, lymphoproliferative disease, and proteinuria, and higher serum creatinine occurred at increased frequency relative to the MMF arm. Creatinine levels in the everolimus arms were stable in follow-up: the mean rise in creatinine over the first 6 months of the open-label phase was 3 micromol/L or greater with everolimus and 7 micromol/L with MMF. However, serum creatinine levels were lower in the MMF group throughout. Death and graft loss were higher in the everolimus arms (not significant). CONCLUSIONS: As part of triple-drug immunosuppression, everolimus (1.5 or 3 mg/day) was as efficacious as MMF, although the side-effect profile featured increased adverse events. Nephrotoxicity/calcineurin-inhibitor-related adverse events will require judicious lowering of CsA exposure with monitoring of everolimus troughs.
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Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Ácido Micofenólico/análogos & derivados , Sirolimo/análogos & derivados , Adolescente , Adulto , Idoso , Quimioterapia Combinada , Everolimo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Segurança , Sirolimo/uso terapêutico , Doadores de Tecidos/estatística & dados numéricosRESUMO
A 48-year-old man with cirrhosis secondary to nonalcoholic steatohepatitis and chronic hepatitis C infection underwent a successful orthotopic liver transplant from a B+ donor without intraoperative complications. His postoperative course was complicated by hemolytic anemia, and he was ultimately diagnosed as having passenger lymphocyte syndrome. Passenger lymphocyte syndrome is a complication of both solid-organ and stem cell transplants. It is caused by donor B lymphocyte production of antibodies causing a primary or secondary immune response to recipient erythrocytes. Most commonly, it is in the setting of minor ABO mismatches, such as with a group B liver transplanted into a group AB recipient. Typically, passenger lymphocyte syndrome presents as a mild, self-limiting hemolytic anemia. Laboratory findings are consistent with other forms of hemolytic anemia including decreased hemoglobin and haptoglobin, elevated reticulocyte count, and indirect hyperbilirubinemia There is no definitive treatment for passenger lymphocyte syndrome or strong evidence to favor a particular treatment regimen. Passenger lymphocyte syndrome has been successfully treated with supportive care and blood transfusions matched to the liver donor. It is prudent that physicians caring for patients who receive ABO mismatched organs have a high index of clinical suspicion for passenger lymphocyte syndrome during the early postoperative period when posttransplant patients present with jaundice and anemia.
Assuntos
Anemia Hemolítica/etiologia , Linfócitos B/imunologia , Icterícia/etiologia , Transplante de Fígado , Eritrócitos/imunologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , SíndromeRESUMO
Organ preservation remains an important contributing factor to graft and patient outcomes. During donor organ procurement and transportation, cellular injury is mitigated through the use of preservation solutions in conjunction with hypothermia. Various preservation solutions and protocols exist with widespread variability among transplant centers. In this review of abdominal organ preservation solutions, evolution of transplantation and graft preservation are discussed followed by classification of preservation solutions according to the composition of electrolytes, impermeants, buffers, antioxidants, and energy precursors. Lastly, pertinent clinical studies in the setting of hepatic, renal, pancreas, and intestinal transplantation are reviewed for patient and graft survival as well as financial considerations. In liver transplants there may be some benefit with the use of histidine-tryptophan-ketoglutarate (HTK) over University of Wisconsin solution in terms of biliary complications and potential cost savings. Renal grafts may experience increased initial graft dysfunction with the use of Euro-Collins thereby dissuading its use in support of HTK which can lead to substantial cost savings. University of Wisconsin solution and Celsior are favored in pancreas transplants given the concern for pancreatitis and graft thrombosis associated with HTK. No difference was observed with preservation solutions with respect to graft and patient survival in liver, renal, and pancreas transplants. Studies involving intestinal transplants are sparse but University of Wisconsin solution infused intraluminally in combination with an intra-vascular washout is a reasonable option until further evidence can be generated. Available literature can be used to ameliorate extensive variation across centers while potentially minimizing graft dysfunction and improving associated costs.
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Over the past 20 years, more than 4,000 patients have undergone an abdominal solid organ transplant at Ohio State University. The 20-year period can be divided into five eras, each defined by an immunosuppressive protocol used during that period. With each successful era came a new immunosuppressive protocol that produced an incremental improvement in outcomes of patients and graft survival resulting from the application of the newest and most sophisticated combination of immunosuppressive drugs. The incidence of acute rejection episodes and graft survival from each era are compared and demonstrate the substantial improvement in results that has been achieved over the past 20 years.
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Terapia de Imunossupressão/história , Imunossupressores/história , Transplante de Rim/história , Faculdades de Medicina/história , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , História do Século XX , Humanos , Imunossupressores/uso terapêutico , Transplante de Rim/imunologia , Tempo de Internação , Ohio , Análise de SobrevidaAssuntos
Glomérulos Renais/fisiologia , Dispositivos Lab-On-A-Chip , Procedimentos Analíticos em Microchip , Animais , Comunicação Celular , Células Cultivadas , Técnicas de Cocultura/instrumentação , Células Endoteliais/fisiologia , Desenho de Equipamento , Humanos , Glomérulos Renais/citologia , Podócitos/fisiologiaRESUMO
BACKGROUND: The utility of cardiac stress testing as a risk-stratification tool before kidney transplantation remains debatable owing to discordance with coronary angiography and outcome yields at different centers. METHODS: We conducted a retrospective study of 273 diabetic kidney transplant recipients from 2006 to 2010. By protocol, all diabetic patients underwent pharmacological radionucleotide stress test or dobutamine stress echocardiography before transplant. We compared the 1-year cardiac outcomes between those with negative stress test results and those with positive stress test results. RESULTS: Patients with a positive stress test result (n=67) underwent coronary angiogram, and significant coronary artery disease (≥70% coronary stenosis) was found in 35 (52.2%) patients. Of the latter, 32 (91.4%) underwent cardiac revascularization (24 underwent cardiac stenting and 8 underwent coronary artery bypass grafting). The rest (n=35) were treated medically. Within 1 year after transplant, the group with positive stress test results experienced more cardiac events (34.3% vs. 3.9%, P<0.001) including acute myocardial infarction (22.4% vs. 3.4%, P<0.001) and ventricular arrhythmias (8.9% vs. 0.05%, P=0.001), higher all-cause mortality (19.4% vs. 4.8%, P<0.001), and cardiac mortality (17.9% vs. 0.9%, P<0.001) compared with the group with negative stress test results. CONCLUSIONS: In this diabetic population, stress testing showed positive and negative predictive values of 34.3% and 96.1%, respectively. Pharmacological cardiac stress testing provided excellent risk stratification in diabetic kidney transplant recipients.
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Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Nefropatias Diabéticas/mortalidade , Teste de Esforço/métodos , Transplante de Rim/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Cardiotônicos , Doença da Artéria Coronariana/terapia , Dobutamina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Valor Preditivo dos Testes , Prevalência , Cintilografia , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sensibilidade e Especificidade , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/terapiaRESUMO
Over the course of the last 25 years, we have seen dramatic improvements in the outcomes following kidney transplantation at The Ohio State University. With the employment of each new pharmacologic or biologic agent, came a reduction in the incidence of acute rejection within the first post-transplant year and beyond as reported in these analyses. This dramatic reduction in acute rejection over progressive eras translated into significantly improved graft survivals. The improved acute rejection prophylaxis provided by progressively more efficacious immunosuppression over time did not come at the expense of increased patient mortality. This improvement was observed in African-American and re-transplant patients, both generally considered to be at high risk of acute rejection and graft loss. Improvements in the outcomes for our pre-transplant sensitized patients have not been realized over the last 10 years. Additionally, African-American recipients who developed new HLA alloantibody reactivities post-transplant fared far worse than their counterparts. Future immunosuppressive regimens that are more efficacious in controlling humoral alloimmune reactivity after transplant are needed if we are to continue improving our outcomes.
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Transplante de Rim , Negro ou Afro-Americano/estatística & dados numéricos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Histocompatibilidade , Hospitais Universitários , Humanos , Imunossupressores/uso terapêutico , Estimativa de Kaplan-Meier , Transplante de Rim/efeitos adversos , Transplante de Rim/etnologia , Transplante de Rim/imunologia , Transplante de Rim/mortalidade , Transplante de Rim/tendências , Ohio , Avaliação de Programas e Projetos de Saúde , Medição de Risco , Fatores de Risco , Fatores de Tempo , Obtenção de Tecidos e Órgãos , Tolerância ao Transplante , Resultado do TratamentoRESUMO
The goals and outcomes of immunosuppression in renal transplantation have changed significantly over the last 30 years. When graft survival rates were relatively low and acute rejection was a frequent occurrence in the early era of transplantation, the goal of immunosuppression was to improve survival and reduce the rate of acute rejection. Today, with excellent graft survival rates and a low incidence of acute rejection, the goal of immunosuppression has shifted toward not only eliminating acute rejection, but also toward reducing the side effects of medications, and maintaining long-term graft function by decreasing chronic nephropathy. Between September 1982-December 2004, 3,211 primary kidney transplant procedures were performed at The Ohio State University. We excluded from analysis all combined transplants as well as patients who were involved in clinical research protocols. Our immunosuppressive protocol changed substantially over this 24-year period, which can be divided into 5 eras in time. Each era is defined by a distinct immunosuppressive protocol that resulted in an incremental improvement in outcomes of patient and graft survival rates. In the present study, the outcomes of each era in patients with previous kidney transplant only are compared and future directions are discussed. The incidence of acute rejection episodes and graft survival from each era are compared and demonstrate the substantial improvement in results that have been achieved over the past 24 years.
Assuntos
Sobrevivência de Enxerto/imunologia , Terapia de Imunossupressão/métodos , Transplante de Rim/imunologia , Doença Aguda , Cadáver , Rejeição de Enxerto/epidemiologia , Hospitais Universitários , Humanos , Terapia de Imunossupressão/tendências , Transplante de Rim/mortalidade , Tempo de Internação , Doadores Vivos , Ohio , Análise de Sobrevida , Fatores de Tempo , Doadores de TecidosRESUMO
UNLABELLED: Shortages of cadaveric kidneys for transplant into rising numbers of patients with end-stage renal failure have increased the demand for kidneys from live donors. The morbidity associated with traditional open donor nephrectomies (ODN) may discourage many candidates. The newer laparoscopic technique has been promoted as having less morbidity. OBJECTIVES: To evaluate outcomes of hand-assisted laparoscopic nephrectomies (HALN) and prospectively compare HALN and ODN. METHODS: After retrospectively reviewing donor and recipient outcomes in 33 HALN (December through August, 2000), we prospectively compared another 47 with 30 ODN performed from September 2000 through April 2001. RESULTS: All 80 HALN were successful, with no requirement to convert to an open procedure. Four donors experienced surgery-related complications: wound infection, retroperitoneal hematoma, prolonged ileus and early small-bowel obstruction, respectively. Two recipients had ureteral complications (1 stricture, 1 leak); 5 experienced delayed graft function, 2 requiring dialysis; and 2 kidneys were lost from infarction. The prospective comparison showed the operative time for HALN (mean 184 min, standard deviation [SD] 39 min) was significantly longer (143 [SD 27] min, p < 0.01), but resulted in less blood loss (p < 0.05). Lengths of time to warm ischemia/early graft function, resumption of oral intake/first bowel movement, and hospital discharge were similar. The abdominal-wall laxity and loss of cutaneous sensation from the flank incision experienced by many ODN patients after was uncommon in the HALN group. Three months after nephrectomy, donor complaints of incisional pain were less common after HALN (p < 0.01). CONCLUSIONS: HALN had good outcomes for donors and recipients, with quicker, more complete recoveries 3 months afterward.