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PURPOSE: The purpose of this study is to evaluate the effect of a high protein and low glycemic load diet in preventing weight gain after kidney transplantation. METHODS: We designed a prospective, single-center, open-label, randomized controlled study to compare the efficacy of a high protein (1.3-1.4 g/kg/day) and low glycemic load diet versus a conventional diet (0.8-1.0 g/kg/day of protein and no recommendations on glycemic load) in preventing weight gain (ClinicalTrials.gov identifier: NCT02883777). A total of 120 patients were evaluated. Patients were followed for 12 months, and the primary outcome was weight maintenance or weight gain lower than 5%. RESULTS: There were no differences in total energy intake, carbohydrates, and total fats between groups. Intervention group (IG) increased protein intake to 1.38 ± 0.56 g/kg/day and decreased the glycemic load to 87.27 ± 4.54 g/day, while control group (CG) had a dietary protein intake of 1.19 ± 0.43 g/kg/day and a glycemic load of 115.60 ± 7.01 g/day. Total fiber intake was greater and trans-fat was lower in IG. Dietetic cholesterol increased in IG over time and was significantly different between groups. Overall, patients had an increase in body weight over time, with a mean increment of 4.1 ± 5.5 kg (5.75%). The percentage of patients who achieved the primary outcome was 50% of sample size, without differences between groups. The glomerular filtration rate improved over time in both groups. Considering 24-h proteinuria and albuminuria, a similar rise was observed in both groups. CONCLUSION: The present dietary intervention was safe, but had no effect on weight gain in kidney transplant subjects. Our findings suggest that other strategies, including alternative dietary and/or pharmacological and psychological interventions might be tested in randomized control trials in order to improve patients' body weight outcomes after transplant.

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This study evaluated the current practices of selecting cold storage preservation solutions in Brazil and their impact on delayed graft function (DGF) incidence and 1-year outcomes in kidney transplant recipients. A retrospective cohort study was conducted, including 3,134 brain-dead deceased donor kidney transplants performed between 2014 and 2015 in 18 Brazilian centers. The most commonly used preservation solution was Euro-collins (EC, 55.4%), followed by Histidine-tryptophan-ketoglutarate (HTK, 30%) and Institut Georges Lopez (IGL-1, 14.6%). The incidence of DGF was 54.4%, with 11.7% of patients requiring dialysis for more than 14 days, indicating prolonged DGF. Upon adjusting for confounding variables, HTK demonstrated a significantly lower risk of DGF than EC (OR 0.7350.82500.926), as did IGL-1 (OR 0.6050.7120.837). Similar protective effects were observed for prolonged DGF when comparing HTK (OR 0.4780.5990.749) and IGL-1 (OR 0.4780.6810.749) against EC. No significant association was found between preservation solutions and 1-year death-censored graft survival. In conclusion, EC was the most frequently used cold storage perfusion solution, demonstrating a higher incidence and duration of DGF compared with HTK and IGL-1, but with no impact on 1-year graft survival.

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Background: The discard of expanded criteria donor (ECD) kidneys is unacceptably high, considering the growing demand for transplantation. Using machine perfusion may reduce the discard rate, increase the number of transplants, and reduce mortality on the waiting list. Methods: We developed a 5-y Markov model to simulate incorporating the pulsatile perfusion machine into the current government-funded healthcare system. The model compared the universal use of static cold storage for all kidneys with the selective use of machine perfusion for ECD kidneys. Real-life data were used to compose the cohort characteristics in this model. This pharmacoeconomic analysis aimed to determine the cost-effectiveness and budgetary impact of using machine perfusion to preserve ECD kidneys. Results: Compared with the universal use of static cold storage, the use of machine perfusion for ECD kidneys was associated with an increase in the number of kidney transplants (n = 1123), a decrease in the number of patients on the waiting list (n = 815), and decrease in mortality (n = 120), with a cost difference of US dollar 4 486 009 in the period. The budget impact analysis revealed an additional cost of US dollar 4 453 749 >5 y. The budget impact analysis demonstrated a progressive reduction in costs, becoming cost-saving during the last year of the analysis. Conclusions: This stochastic model showed that incorporating machine perfusion for ECD kidneys is most often a dominant or cost-effective technology associated with an increase in the number of transplants and a reduction in the number of patients on the waiting list, reducing mortality on the waiting list.

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PURPOSE: To evaluate the reduction of patients' bed rest time after percutaneous renal biopsy (PRB) from 24 to 8 h using the Nursing Outcomes Classification (NOC). METHODS: This was a randomized clinical trial registered with Clinical Trials number NCT04629235. The sample comprised 16 patients in the intervention group and 18 in the control group. In the intervention group, the rest time was modified to 8 h, and afterward, the patients were released to ambulate, whereas the control patients remained at absolute rest for 24 h after PRB according to institutional protocol. All patients were observed for 24 h and evaluated at five time points with the outcomes and indicators of the NOC: before the biopsy, immediately after, at the 8th hour, at the 12th hour, and at the 24th hour after the procedure. RESULTS: In the 170 evaluations performed, statistically significant differences were identified in the outcome Comfort status: physical and the indicators "physical well-being and comfortable position." None of the complications were related to reduced bed rest time. CONCLUSIONS: Reducing patients' bed rest time from 24 to 8 h did not increase complications from PRB, and using the NOC provided a standardized and reliable assessment. IMPLICATIONS FOR NURSING PRACTICE: Important evidence was identified for patient care after PRB, demonstrating the positive impact on patient comfort and the possibility of reducing costs to the institution and the workload of the multidisciplinary team. In addition, these findings may contribute to strengthening the use of NOC in clinical practice, teaching, and research.

OBJETIVO: Avaliar a redução do tempo de repouso no leito de pacientes após biópsia renal percutânea de 24 para 8 horas, por meio de resultados e indicadores clínicos da Nursing Outcomes Classification/NOC. MÉTODOS: Ensaio clínico randomizado registrado no Clinical Trials (NCT04629235). A amostra contou com 16 pacientes no Grupo Intervenção e 18 no Grupo Controle. No Grupo Intervenção o tempo de repouso foi modificado para 8 horas, e após os pacientes foram liberados para deambular; enquanto no Grupo Controle os pacientes se mantiveram em repouso absoluto por 24 horas após biópsia renal percutânea, conforme protocolo institucional. Todos os pacientes foram observados por 24 horas e avaliados em cinco momentos distintos, com resultados e indicadores da Nursing Outcomes Classification/NOC: antes da biópsia, imediatamente após, na 8ª hora, na 12ª hora e na 24ª hora após o procedimento. RESULTADOS: Nas 170 avaliações realizadas foi identificada diferença estatisticamente significativa nos escores do resultado Estado de conforto: físico, e nos indicadores "bem-estar físico e posição confortável". Nenhuma das complicações foi relacionada com a redução do tempo de repouso no leito. CONCLUSÕES: A redução do tempo de repouso no leito dos pacientes de 24 para 8 horas não aumentou as complicações decorrentes da biópsia renal percutânea. O uso da Nursing Outcomes Classification/NOC favoreceu uma avaliação padronizada e fidedigna. IMPLICAÇÕES PARA A PRÁTICA: Identificou-se evidências importantes para o cuidado ao paciente após biópsia renal percutânea, demonstrando o impacto positivo no conforto dos pacientes, além da possibilidade de diminuição de custos à instituição e da sobrecarga no trabalho da equipe multidisciplinar. Somado a isso, estes resultados poderão contribuir para o fortalecimento do uso da Nursing Outcomes Classification/NOC na prática clínica, ensino e pesquisa.

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ABSTRACT Introduction: Patients on renal replacement therapy (RRT) and kidney transplant recipients (KTR) present multiple factors that may increase the risk of death from coronavirus disease 2019 (COVID-19). This study aimed to evaluate the incidence and impact of COVID-19 in RRT patients and KTRs. Methods: Between March 2020 and February 2021, we monitored the RRT population of thirteen dialysis facilities that refer patients for transplantation to our center, a tertiary hospital in Southern Brazil. In the same period, we also monitor COVID-19 incidence and mortality in our KTR population. Demographical, clinical, and COVID-19-related information were analyzed. Results: We evaluated 1545 patients in the dialysis centers, of which 267 (17.4%) were infected by COVID-19 and 53 (19.9%) died. Among 275 patients on the kidney transplant waiting list, 63 patients (22.9%) were infected and seven (11.1%) died. COVID-19 was the leading cause of death (29.2%) among patients on the waiting list. Within the population of 1360 KTR, 134 (9.85%) were diagnosed with COVID-19 and 20 (14.9%) died. The number of kidney transplants decreased by 56.7% compared with the same period in the previous twelve months. Conclusion: In the study period, patients on RRT and KTRs presented a high incidence of COVID-19 and high COVID-19-related lethality. The impact on the patients on the transplant waiting list was less pronounced. The lethality rate observed in both cohorts seems to be related to age, comorbidities, and disease severity.

Resumo Introdução: Pacientes em terapia renal substitutiva (TRS) e receptores de transplante renal (RTR) apresentam múltiplos fatores que podem aumentar o risco de óbito por doença do coronavírus 2019 (COVID-19). Este estudo teve como objetivo avaliar incidência e impacto da COVID-19 em pacientes em TRS e RTR. Métodos: Entre Março de 2020 e Fevereiro de 2021, monitoramos a população em TRS de treze unidades de diálise que encaminham pacientes para transplante ao nosso centro, um hospital terciário no Sul do Brasil. No mesmo período, também monitoramos a incidência e mortalidade da COVID-19 em nossa população de RTR. Foram analisadas informações demográficas, clínicas e relacionadas à COVID-19. Resultados: Avaliamos 1545 pacientes nos centros de diálise, dos quais 267 (17,4%) foram infectados pela COVID-19 e 53 (19,9%) foram a óbito. Entre 275 pacientes na lista de espera para transplante renal, 63 (22,9%) foram infectados e sete (11,1%) foram a óbito. COVID-19 foi a principal causa de óbito (29,2%) entre pacientes na lista de espera. Dentre a população de 1360 RTR, 134 (9,85%) foram diagnosticados com COVID-19 e 20 (14,9%) foram a óbito. O número de transplantes renais diminuiu em 56,7% comparado ao mesmo período nos doze meses anteriores. Conclusão: No período do estudo, pacientes em TRS e RTR apresentaram alta incidência de COVID-19 e alta letalidade relacionada à COVID-19. O impacto nos pacientes na lista de espera para transplante foi menos pronunciado. A taxa de letalidade observada em ambas as coortes parece estar relacionada à idade, comorbidades e gravidade da doença.

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INTRODUCTION: Patients on renal replacement therapy (RRT) and kidney transplant recipients (KTR) present multiple factors that may increase the risk of death from coronavirus disease 2019 (COVID-19). This study aimed to evaluate the incidence and impact of COVID-19 in RRT patients and KTRs. METHODS: Between March 2020 and February 2021, we monitored the RRT population of thirteen dialysis facilities that refer patients for transplantation to our center, a tertiary hospital in Southern Brazil. In the same period, we also monitor COVID-19 incidence and mortality in our KTR population. Demographical, clinical, and COVID-19-related information were analyzed. RESULTS: We evaluated 1545 patients in the dialysis centers, of which 267 (17.4%) were infected by COVID-19 and 53 (19.9%) died. Among 275 patients on the kidney transplant waiting list, 63 patients (22.9%) were infected and seven (11.1%) died. COVID-19 was the leading cause of death (29.2%) among patients on the waiting list. Within the population of 1360 KTR, 134 (9.85%) were diagnosed with COVID-19 and 20 (14.9%) died. The number of kidney transplants decreased by 56.7% compared with the same period in the previous twelve months. CONCLUSION: In the study period, patients on RRT and KTRs presented a high incidence of COVID-19 and high COVID-19-related lethality. The impact on the patients on the transplant waiting list was less pronounced. The lethality rate observed in both cohorts seems to be related to age, comorbidities, and disease severity.

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BACKGROUND: The chronic use of immunosuppressive drugs is a key risk factor of death because of coronavirus disease 2019 (COVID-19) in kidney transplant recipients (KTRs), although no evident association between the class of immunosuppressive and outcomes has been observed. Thus, we aimed to compare COVID-19-associated outcomes among KTRs receiving 3 different immunosuppressive maintenance regimes. METHODS: This study included data from 1833 KTRs with COVID-19 diagnosed between March 20 and April 21 extracted from the national registry before immunization. All patients were taking calcineurin inhibitor associated with mycophenolate acid (MPA, n = 1258), azathioprine (AZA, n = 389), or mammalian targets of rapamycin inhibitors (mTORi, n = 186). Outcomes within 30 and 90 d were assessed. RESULTS: Compared with patients receiving MPA, the 30-d (79.9% versus 87.9% versus 89.2%; P < 0.0001) and 90-d (75% versus 83.5% versus 88.2%; P < 0.0001) unadjusted patient survivals were higher in those receiving AZA or mTORi, respectively. Using adjusted multivariable Cox regression, compared with patients receiving AZA, the use of MPA was associated with a higher risk of death within 30 d (adjusted hazard ratio [aHR], 1.70; 95% confidence interval [CI], 1.21-2.40; P = 0.003), which was not observed in patients using mTORi (aHR, 0.78; 95% CI, 0.45-1.35; P = 0.365). At 90 d, although higher risk of death was confirmed in patients receiving MPA (aHR, 1.46; 95% CI, 1.09-1.98; P = 0.013), a reduced risk was observed in patients receiving mTORi (aHR, 0.59; 95% CI, 0.35-0.97; P = 0.04) compared with AZA. CONCLUSIONS: This national cohort data suggest that, in KTRs receiving calcineurin inhibitor and diagnosed with COVID-19, the use of MPA was associated with higher risk of death, whereas mTORi use was associated with lower risk of death.

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Delayed graft function (DGF) is a common complication of kidney transplantation and frequently leads to the necessity of surveillance biopsies. The purpose of this study is to describe the histological findings in surveillance biopsies of deceased donor kidney transplant recipients and evaluate the risk factors for graft outcomes. This is a monocentric, retrospective study including kidney transplant recipients that underwent a graft biopsy during the DGF period between January 2006 and July 2019. 356 biopsies were performed in 335 deceased donor transplant recipients. Biopsies were analyzed according to the Banff classification. The main histological findings were: acute tubular necrosis in 150 biopsies (42.1%), acute rejection in 96 biopsies (26.9%), and borderline findings in 91 biopsies (25.5%). In the multivariate analysis, recipient age (p = 0.028) and DGF duration (p = 0.005) were associated with rejection, antibody-induction with anti-thymocyte globulin (ATG) was protective (p = 0.001). The occurrence of rejection was associated with lower death-censored graft survival (log-rank; p = 0.009). Surveillance biopsies of kidney grafts experiencing DGF remain an essential tool for the care of kidney transplant recipients. The recipient's age and duration of DGF are independent risk factors for acute rejection, while antibody-induction therapy with ATG is associated with protection from its occurrence.

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