RESUMO
Low-grade proteinuria and systolic hypertension (SHT) are risk factors for allograft failure. Both are dynamic variables and their relationship is not independent. We have simultaneously analyzed the effects of proteinuria and SHT on graft outcomes in 805 adult Kidney Transplant Recipients and impact of their changes over time. Proteinuria and systolic blood pressure (SBP) were recorded for years 1 and 3 posttransplantation. Subjects with proteinuria >1 g/day were excluded. Patients were divided into groups based on proteinuria (Absent(A) <150 mg/day or low-grade(P)150 mg-1 g/day) and blood pressure (Normotensive-SBP <140 mmHg or hypertensive-SBP ≥ 140 mmHg). Graft survival was assessed in all four groups over 10 years by multivariate analysis. At the three annual time points (Year 1, 2 and 3) hypertensive patients with proteinuria had the worst graft survival. Patients with persistent proteinuria between years 1-2 and 2-3 had the poorest graft survival with an improvement if proteinuria regressed (P-A), especially in the Hypertensive group. The impact of proteinuria was highest in persistently hypertensive patients between years 1-3. Thus both proteinuria and SHT were associated with poor graft survival and the combination of the two led to the worst outcomes. Importantly, SHT was associated with significantly worse outcomes in patients with proteinuria. Patient cohort with SHT and low-grade proteinuria represent a selective group that might benefit from intervention.
Assuntos
Transplante de Rim , Proteinúria/fisiopatologia , Pressão Sanguínea , Sobrevivência de Enxerto , Humanos , Estudos Longitudinais , Estudos RetrospectivosRESUMO
BACKGROUND: The STEPP group was established to investigate factors that affect long-term transplant outcomes including quality of life and other patient-reported outcomes between different transplant centers and patients. METHODS: Data were collected for 2,650 patients whose first renal transplant took place between 1992 and 2003 in five UK centers. Univariable and multivariable survival analyses were performed using eleven candidate explanatory variables. RESULTS: Graft survival was worse in Black (B) patients (HR B v W 1.57 95% CI 1.10, 2.24), and in South Asian (A) patients (HR A v W 1.39 95% CI 1.03, 1.85) compared to Whites (W) after adjusting for other factors including HLA mismatch, and time on dialysis. Time spent on dialysis pre-transplantation was non-linearly associated with patient, but not death-censored graft survival. Losing a functioning graft was a strong predictor of patient death. One site had both the best graft and the worst patient survival. CONCLUSIONS: Differences in patient and graft survival between ethnic groups cannot be explained by currently recognized factors. These, and the complex balance between optimum patient and graft survival which differs between sites in this study require further investigation.
Assuntos
Sobrevivência de Enxerto , Transplante de Rim/etnologia , Adolescente , Adulto , Povo Asiático/estatística & dados numéricos , População Negra/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Qualidade de Vida , Diálise Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , População Branca/estatística & dados numéricosRESUMO
Renal transplant recipients are at increased risk for development of nonmelanoma skin carcinoma, owing to a number of causes, including ultraviolet exposure. It has been shown that, despite education, there is poor compliance by these patients with the advice given for protecting their skin from the sun. This repeat study was conducted to determine whether there had been an improvement in compliance over the last 6 years. Two hundred twenty-seven patients were invited to complete the questionnaire used in the previous study. This questionnaire was designed to establish whether patients understood the need for extra care, whether they recalled any education about protective measures, and what actual measures were taken. There was a significant increase in the proportion of patients taking appropriate precautions. Hence there has been a significant improvement in the compliance of renal transplant recipients in Yorkshire with skin protection measures since this was originally audited in 1998.
Assuntos
Transplante de Rim/fisiologia , Cooperação do Paciente , Queimadura Solar/prevenção & controle , Protetores Solares/uso terapêutico , Suscetibilidade a Doenças , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Transplante de Rim/efeitos adversos , Transplante de Rim/psicologia , Auditoria Médica , Educação de Pacientes como Assunto , Inquéritos e QuestionáriosRESUMO
The urological complications of renal transplantation are well documented. In 1990, our experience of 507 consecutive renal transplants using the Leadbetter-Politano technique, which was unsplinted in the vast majority of patients, had a ureteric complication rate of 7.7%. Here, we report the long-term incidence and management of our ureteric complications in 1186 consecutive renal transplants done over the following 11 years using an extravesical onlay stented ureteroneocystostomy. We report a considerable reduction in the urological complications of renal transplantation to 3.8%. Furthermore, we were able to use percutaneous radiological techniques to salvage the majority (84.7%) of ureteric complications. Recourse to surgery was required rarely but enabled salvage of all treatment failures.
Assuntos
Cistostomia/métodos , Transplante de Rim/efeitos adversos , Transplante de Rim/métodos , Stents , Ureterostomia/métodos , Humanos , Incidência , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Obstrução Ureteral/cirurgiaRESUMO
We examined the influence of donor and recipient age as well as close donor and recipient age matching by analysis of the actuarial survival of 397 consecutive first cadaveric renal transplants carried out in the years 1987 to 1990. Graft failure was defined as return to dialysis, transplant nephrectomy, or death of the recipient from any cause. Overall 1-, 2-, and 3-year actuarial graft survival was 87, 84, and 79%. No effect on graft survival in adult patients was seen of advanced age of either donor or recipient. The source of the donor whether from within or outside the North Western Regional Health Authority did not influence outcome whatever the donor age. Results from patients in whom the donor was within 5 years of the recipient's age were no different from those obtained when the age difference was greater than 5 years. These data do not support the hypothesis that close age matching influences graft survival. Age matching need not be used as a recipient selection criterion. As neither recipient nor donor age influenced early graft survival, consideration should be given to increasing the average age of both donors and recipients.
Assuntos
Envelhecimento/fisiologia , Sobrevivência de Enxerto/fisiologia , Transplante de Rim/fisiologia , Adolescente , Adulto , Idoso , Cadáver , Criança , Pré-Escolar , Humanos , Lactente , Transplante de Rim/imunologia , Transplante de Rim/mortalidade , Pessoa de Meia-Idade , Taxa de SobrevidaRESUMO
The object of the study presented here was to test whether measurement of blood or urine IL-6 or TNF-alpha could discriminate between the most common causes of renal allograft dysfunction, thus avoiding a biopsy. We present data here in which serum and urine IL-6 and TNF-alpha levels were measured at the same time as a diagnostic renal biopsy was performed. TNF-alpha and IL-6 were measured by sandwich ELISA. Thirty patients had acute cellular rejection, 18 had acute tubular necrosis/CsA toxicity, and 9 had chronic vascular rejection. There was no difference in the levels of IL-6 measured in serum and urine among the three categories of graft dysfunction (t < 1.31; P > 0.20). A similar result with considerable overlap between the groups was seen with TNF-alpha (t < 0.78; P > 0.44). Stratifying the results according to the precise immunosuppressive therapy, CsA dose, body weight, CsA level, body temperature, serum creatinine, the number of previous rejection episodes, original cause of renal failure, or the time elapsed since the transplant did not alter the results. The ratio of serum IL-6 divided by trough CsA level was compared among the three groups and there was no significant difference among them (t < 1.79; P > 0.09). In the light of our results, we therefore suggest that previously published reports of the clinical value of serum and or urine IL-6 and or TNF-alpha in relatively small numbers of patients, not all of whom had been biopsied and in whom rigorous clinical and statistical criteria had not been met, should be viewed with caution.
Assuntos
Rejeição de Enxerto/diagnóstico , Interleucina-6/sangue , Transplante de Rim/patologia , Transplante de Rim/fisiologia , Necrose Tubular Aguda/diagnóstico , Fator de Necrose Tumoral alfa/análise , Anticorpos Monoclonais , Biomarcadores/sangue , Biomarcadores/urina , Biópsia , Reações Cruzadas , Ciclosporina/efeitos adversos , Ciclosporina/sangue , Ciclosporina/toxicidade , Ensaio de Imunoadsorção Enzimática , Rejeição de Enxerto/patologia , Humanos , Interleucina-6/urina , Necrose Tubular Aguda/patologia , Proteínas Recombinantes/análise , Fator de Necrose Tumoral alfa/urinaRESUMO
Transforming growth factor beta (TGF beta 1) is a prosclerotic cytokine implicated in several disease processes. Recent reports have demonstrated a role for TGF beta 1 in experimental models of glomerulonephritis, focusing attention on the relevance of TGF beta to renal fibrogenesis in human disease. The study reported here was designed to investigate whether circulating, active TGF beta 1 could be detected in renal allograft recipients, and whether plasma levels correlated with episodes of rejection, a process involving both inflammation and fibrosis. We have developed an ELISA assay for active TGF beta 1 using commercially available antibodies, and measured plasma levels in 43 healthy controls, 11 patients with membranous nephropathy (MN) and impaired renal function, 17 transplant recipients with stable renal function, 27 patients with acute cellular rejection, 7 patients with chronic vascular rejection, and 10 patients with acute tubular necrosis and/or cyclosporine toxicity. In the last three groups diagnoses were biopsy-proved, and all samples were collected at the time of biopsy. TGF beta 1 was also measured in urine samples from 8, 11, 0, 9, 4, and 7 individuals, respectively, from each group. TGF beta 1 was not detected in plasma from any of the healthy controls or any of the MN patients, (detection limit of assay 0.1 ng/ml). By comparison, it was significantly increased in all groups of transplant recipients (unpaired t test, P < 0.01), but there were no significant differences between the transplant groups. Plasma TGF beta 1 level did not correlate with renal function (estimated by either serum creatinine or reciprocal creatinine), kidney donor age, recipient age, time since transplantation, or cyclosporine plasma trough level. TGF beta 1 was found in every urine sample tested from healthy controls, with a range from 1 ng/ml to 35 ng/ml. Among the 20 transplant patient urines tested, 2 were negative, 18 were positive but within the range determined for the healthy controls. There were no significant differences between the groups.
Assuntos
Transplante de Rim/fisiologia , Fator de Crescimento Transformador beta/sangue , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Doença Crônica , Creatinina/sangue , Ciclosporina/efeitos adversos , Feminino , Glomerulonefrite Membranosa/sangue , Glomerulonefrite Membranosa/imunologia , Rejeição de Enxerto/sangue , Humanos , Transplante de Rim/imunologia , Masculino , Pessoa de Meia-Idade , Valores de Referência , Análise de Regressão , Transplante Homólogo/fisiologiaRESUMO
Pruritus is a distressing symptom affecting up to 90% of dialysis patients. Conventional treatment with antihistamines is often ineffective and may have unacceptable side effects. Serotonin (5-hydroxytryptamine type 3 [5-HT(3)]) is known to enhance pain perception and pruritic symptoms through receptors on sensory nerve endings. Antagonism of 5-HT(3) receptors may be of use in treating uremic pruritus. We randomly assigned 16 hemodialysis patients with persistent pruritus to treatment with the 5-HT(3)-receptor antagonist, ondansetron (8 mg), or placebo three times daily for 2 weeks each in a prospective, placebo-controlled, double-blind crossover study. Patients scored their intensity of pruritus daily on a 0-to-10 visual analogue scale (0 = no pruritus, 10 = maximal pruritus), and daily use of antihistamines as escape medication was recorded. The median daily pruritus score did not change significantly during active or placebo treatment (preondansetron, 5. 3; interquartile range [IQR], 3.4 to 6.3; during ondansetron, 3.9; IQR, 2.7 to 5.0; P = not significant; preplacebo, 3.7; IQR, 3.0 to 4. 6; during placebo, 3.6; IQR, 2.4 to 4.8; P = not significant). The median daily percentage of escape medication use decreased from 21% (IQR, 9 to 61) to 9% (IQR, 0 to 33) with ondansetron (P = not significant) and from 53% (IQR, 0 to 88) to 5% (IQR, 0 to 31) with placebo (P = not significant). There was no difference in predialysis biochemistry test results or dialysis efficacy during treatment phases. Ondansetron does not improve pruritus in hemodialysis patients. Use of antihistamines decreased with both ondansetron and placebo.
Assuntos
Ondansetron/uso terapêutico , Prurido/tratamento farmacológico , Prurido/etiologia , Diálise Renal/efeitos adversos , Antagonistas da Serotonina/uso terapêutico , Adulto , Idoso , Estudos Cross-Over , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Uremia/terapiaRESUMO
AIMS: To determine whether polymorphisms of the genes encoding donor or recipient interleukin 1alpha (IL-1alpha), tumour necrosis factor alpha (TNFalpha), or IL-4 have any impact on the incidence of acute rejection after renal transplantation. METHODS: All donors and recipients were genotyped for three polymorphisms in the three cytokine genes: IL1A -889, TNFA -308, and IL4 -590. RESULTS: Statistical analysis of the data obtained revealed no association between the cytokine gene polymorphisms tested and the incidence of post-transplant acute rejection. After stratification for human leucocyte antigen (HLA) matching, it was found that kidneys from donors positive for the TNFA-A allele had a significantly increased incidence of acute rejection in HLA-DR mismatched transplants. CONCLUSIONS: This finding argues for prospective TNFA genotyping of renal donors, with avoidance of allocation of kidneys from donors positive for the TNFA-A allele to HLA-DR mismatched recipients.
Assuntos
Citocinas/genética , Rejeição de Enxerto/genética , Transplante de Rim/imunologia , Doença Aguda , Genótipo , Teste de Histocompatibilidade , Humanos , Interleucina-1/genética , Interleucina-4/genética , Polimorfismo Genético , Polimorfismo de Fragmento de RestriçãoRESUMO
Six renal transplant recipients underwent a series of incremental exercise experiments. Minute ventilation (VE), carbon dioxide production rate (VCO2), and arterial blood chemistry were measured at rest and while subjects exercised on a stationary bicycle. Four of the subjects performed a similar experiment while exercising on a static rowing machine. Within each subject, arterial potassium concentration ([K+]a) was linearly related to VCO2 and VE during exercise. The slope of the relationship between [K+]a and VCO2 was similar in the cycling and rowing experiments. This implies that the absorption of potassium by resting muscle does not significantly limit the arterial hyperkalemia seen during exercise. When VE, VCO2, and [K+]a were measured 1 and 5 min after the end of cycling there was no correlation, whereas VE continued to be closely correlated with VCO2. The relationship demonstrated between change in [K+]a and VCO2 in these experiments is compatible with change of [K+]a acting as a respiratory signal during exercise but not during recovery from exercise in humans.
Assuntos
Potássio/sangue , Respiração , Adulto , Ciclismo , Dióxido de Carbono/metabolismo , Feminino , Humanos , Masculino , Esforço Físico , Análise de Regressão , Fatores de TempoRESUMO
Flow of water under foam neoprene wet suits could halve insulation that the suits provided, even at rest in cold water. On the trunk conductance of this flow was approximately 6.6 at rest and 11.4 W . m-2 . C-1 exercising; on the limbs, it was only 3.4 at rest and 5.8 W . m-2 . degrees C-1 exercising; but during vasoconstriction in the cold, skin temperatures on distal parts of limbs were lower than were those of the trunk, allowing adequate metabolic responses. In warm water, minor postural changes and movement made flow under suits much higher, approximately 60 on trunk and 30 W . m-2 . degrees C-1 on limbs, both at rest and at work. These changes in flow allowed for a wide range of water temperatures at which people could stabilize body temperature in any given suit, neither overheating when exercising nor cooling below 35 degrees C when still. Even thin people with 4- or 7- mm suits covering the whole body could stabilize their body temperatures in water near 10 degrees C in spite of cold vasodilatation. Equations to predict limits of water temperature for stability with various suits and fat thicknesses are given.
Assuntos
Regulação da Temperatura Corporal , Temperatura Baixa , Imersão , Roupa de Proteção , Adulto , Composição Corporal , Eletrocardiografia , Feminino , Humanos , Masculino , Neopreno , Esforço Físico , Postura , Temperatura Cutânea , Fatores de Tempo , VasodilataçãoRESUMO
OBJECTIVE: To establish whether estimation of creatinine clearance (CrCl) from serum creatinine, gender, age, and weight might reduce the number of 24-hour urine and dialysate collections required to monitor adequacy of delivered dialysis on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: Retrospective single-center study. SETTING: University Hospital. PATIENTS: Creatinine excretion and CrCl were measured in 187 24-hour urine and dialysate collections from 99 CAPD patients (55 male, 44 female). Multiple regression analysis was used to estimate creatinine excretion from age and weight in males and females. CrCl was derived and also calculated using the Cockcroft-Gault and Mitch-Walser formulas. Positive and negative predictive values for indicating adequacy of dialysis were determined. RESULTS: Measured and derived CrCl were correlated (males: r = 0.85; females: r = 0.83; p < 0.001), but agreement was poor (95% limits of agreement: males, 26.05 to -25.75 L/wk; females, 37.47 to -19.49 L/wk). Taking the minimum acceptable CrCl as 60 L/week, the respective positive predictive values of the derived, Cockcroft, and Mitch methods in predicting underdialysis were 88%, 100%, and 100% in males and 88%, 88%, and 89% in females. Negative predictive values were 83%, 57%, and 53% in males and 53%, 48%, and 45% in females. CONCLUSION: A derived CrCl > 60 was not predictive of adequate dialysis. Because the detection of underdialysis is our objective, formal clearance studies should be performed in this group. A derived CrCl < 60 L/wk was predictive of underdialysis in males and females and an increase in dialysis dose without formal clearance measurements could be suggested in these patients. The use of this approach could allow an important reduction in the number of clearance studies required to monitor CAPD adequacy.
Assuntos
Creatinina/metabolismo , Diálise Peritoneal Ambulatorial Contínua , Adulto , Fatores Etários , Idoso , Peso Corporal , Creatinina/sangue , Creatinina/urina , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Análise Multivariada , Cooperação do Paciente , Diálise Peritoneal Ambulatorial Contínua/estatística & dados numéricos , Valor Preditivo dos Testes , Análise de Regressão , Estudos Retrospectivos , Fatores Sexuais , Urina/química , Urina/fisiologiaRESUMO
Donation after cardiac death (DCD) provides grafts in renal transplantation but is associated with increased early graft dysfunction. Cold ischemia time (CIT) is a factor that is thought to affect outcomes in renal transplantation. We sought to assess the impact of the length of CIT among our DCD cohort of renal transplants performed between April 2002 and December 2009. Since the median CIT was 15.5 hours, we formed two groups CIT < 15.5 (n = 100) and CIT > 15.5 hr (n = 98). We demonstrated an increased incidence of DGF among the extended CIT group, but the long outcomes and the mean graft function were otherwise comparable. In conclusion, CIT affects early graft function; every effort should be made to minimize it in renal transplantation using DCD kidneys.
Assuntos
Criopreservação , Morte , Isquemia , Transplante de Rim , Rim/irrigação sanguínea , Obtenção de Tecidos e Órgãos , Adulto , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Análise de Sobrevida , Fatores de TempoRESUMO
With the increase of donation after cardiac death (DCD) now including procurements for not only kidney but also liver, pancreas, and lung transplantations, we analyze whether multiorgan DCD retrievals have a negative impact on immediate and short-term renal transplant outcomes due to increased length of time of explantation of the kidney from the donor and the associated risks of re-warming. We performed a retrospective study of all DCD donors from 2002 to 2009 at a single unit. Immediate and short-term outcomes between kidney-only versus multiorgan retrieval were compared. Cold ischaemia was significant between the two groups (P = .04), but all other variables were nonsignificant. The results show that immediate graft function, rates of acute rejection and graft/recipient survival are comparable when DCD allografts are procured from both multiorgan and kidney-only donors. The comparable outcomes from kidney-only and multiorgan donations in this study may be due to by the highly selective use of donors for multiorgan DCD donation. This selectivity may explain the "better" quality of kidney for these cases in which patients were able to tolerate potentially injurious rewarming.
Assuntos
Morte , Rim , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Resultado do Tratamento , Adulto , Feminino , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
The United Kingdom has no national sharing scheme for kidneys received from donation after cardiac death (DCD). Therefore, both kidneys retrieved by a transplant team are implanted at a single unit, often sequentially. This study analyzes the impact of a prolonged cold ischaemia time on the second transplanted kidney and the effects on short-term and long-term outcomes in all our DCD renal implants from 2002 to 2009. Cold ischaemia time was significantly longer with the second kidney (P = .04) as was delayed graft function (P = .02). Acute rejection was increased in the first transplanted kidney (P < .001). Five-year patient survival was comparable between groups, but 5-year graft survival was higher in the second transplanted group (P = .04). The results confirm that, provided recipient centers are willing to accept higher initial rates of delayed graft function, it is acceptable to transplant DCD grafts sequentially without jeopardizing long-term graft or recipient outcome.