RESUMO
INTRODUCTION: Chronic kidney disease can lead to dysfunction of the respiratory, cardiac, and musculoskeletal systems, altering the body's metabolism. Renal transplantation and hospital physiotherapy, through specific protocols, can improve these dysfunctions. OBJECTIVES: This study evaluates the impact of a hospital physiotherapeutic protocol in quality of life (QoL), respiratory muscle strength, peak expiratory flow, and 6-minute walk test (6MWT) in the preoperative, first, and fifth days after renal transplantation. METHODS: We evaluated 39 patients who received a renal transplant at Clinics Hospital of University of Campinas for respiratory muscle strength, expiratory peak flow, and functional capacity by the 6MWT. The short form-36 quality of life questionnaire was applied to 12 patients. RESULTS: We observed a significant reduction in respiratory muscle strength and peak expiratory flow in the first postoperative day. On postoperative day 5, there was improvement in respiratory muscle strength and expiratory peak flow. However, aerobic capacity measured by 6MWT remained below predicted. Analysis of QoL showed an improvement in almost all analyzed domains after transplantation. CONCLUSION: A specific physiotherapeutic protocol applied early after transplantation provided recovery of respiratory muscle strength and QoL. However, longer training is necessary to obtain adequate aerobic rehabilitation.
Assuntos
Tolerância ao Exercício/fisiologia , Transplante de Rim/reabilitação , Qualidade de Vida , Insuficiência Renal Crônica/fisiopatologia , Respiração , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Período Pós-Operatório , Insuficiência Renal Crônica/reabilitação , Insuficiência Renal Crônica/cirurgia , Testes de Função Respiratória , Músculos Respiratórios/fisiopatologia , Inquéritos e Questionários , Resultado do Tratamento , Teste de CaminhadaRESUMO
BACKGROUND: Renal transplant is the therapy of choice for patients with chronic renal disease. In recent years, improvement in immunosuppressive drugs reduced early graft loss associated with acute rejection. However, vascular thrombosis, accounting for 5% of early graft loss, can sensitize the recipient for human leukocyte antibodies, reducing the chance for a second transplant. The aim of this study was to identify risk factors for vascular thrombosis in a single transplant center, to design specific prevention protocol. METHODS: This was a retrospective, case-control study. From the Renal Transplant Unit database, we identified 21 cases of vascular thrombosis in recipients of kidneys from deceased donors. Recipients from the contralateral kidney from the same donor, without vascular complications, were assigned to the control group. Data analyzed included donor, recipient, transplant surgery, and post-operative follow-up. The local ethics committee approved the protocol. RESULTS: Thrombosis and control groups were comparable for recipient characteristics, cold ischemia time, organ side (right or left), and site of arterial anastomosis. We observed an increased risk for vascular thrombosis in kidneys with multiple veins (odds ratio, 11.32; P = .03). Organ retrieval surgery complications, such as vascular lesions or heterogeneous perfusion, despite normal pre-implantation biopsy, were considered risk factors for vascular thrombosis within the first post-operative day (odds ratio, 7.1; P = .03). CONCLUSIONS: In this series, multiple renal vein and organ retrieval surgery complications were risk factors for early vascular thrombosis.
Assuntos
Transplante de Rim/efeitos adversos , Trombose/epidemiologia , Trombose/etiologia , Coleta de Tecidos e Órgãos/efeitos adversos , Adulto , Estudos de Casos e Controles , Isquemia Fria/efeitos adversos , Feminino , Humanos , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Doadores de TecidosRESUMO
The impact of borderline rejection in renal graft remains controversial. The aim of this study was to analyze the presence of C4d deposits in peritubular capillaries and macrophage infiltration in renal biopsies with diagnosis of borderline rejection ant its effect on graft function. Thirty-one renal transplant recipients with a diagnosis of borderline rejection were included. Initial and sequential biopsies were analyzed for morphology, C4d, and macrophage staining and compared with clinical data. Initial biopsies showed 12 samples to be C4d positive, associated with a higher incidence of delayed graft function, earlier post-transplantation time, higher acute tubular necrosis score, capillaritis, and glomerular macrophage infiltration, and a lower level of tubulitis, interstitial fibrosis, and tubular atrophy compared with the C4d-negative samples. In sequential biopsies, 5 patients from the negative group turned C4d positive. Patients with ≥1 positive C4d biopsy (n = 17) showed lower renal graft function at 6 months (1.8 ± 0.8 vs 1.4 ± 0.5 mg/dL; P < .01), 1 year (2.1 ± 1 vs 1.5 ± 0.5 mg/dL; P < .01), and 2 years (2.3 ± 1.3 vs 1.5 ± 0.7 mg/dL; P < .05) of follow-up. The expression of C4d in peritubular capillaries of renal biopsies classified as borderline rejection was associated with a worse prognosis for the renal allograft.
Assuntos
Complemento C4b/metabolismo , Função Retardada do Enxerto/metabolismo , Transplante de Rim , Rim/metabolismo , Adulto , Biomarcadores/metabolismo , Biópsia , Capilares/metabolismo , Feminino , Rejeição de Enxerto/metabolismo , Humanos , Rim/patologia , Túbulos Renais/irrigação sanguínea , Túbulos Renais/patologia , Macrófagos/metabolismo , MasculinoRESUMO
INTRODUCTION: Urinary tract infection (UTI) is the most common infection posttransplant. However, the risk factors for and the impact of UTIs remain controversial. The aim of this study was to identify the incidence of posttransplant UTIs in a series of renal transplant recipients from deceased donors. Secondary objectives were to identify: (1) the most frequent infectious agents; (2) risk factors related to donor; (3) risk factors related to recipients; and (4) impact of UTI on graft function. PATIENTS AND METHODS: This was a retrospective analysis of medical records from renal transplant patients from January to December 2010. Local ethics committee approved the protocol. RESULTS: The incidence of UTI in this series was 34.2%. Risk factors for UTI were older age, (independent of gender), biopsy-proven acute rejection episodes, and kidneys from deceased donors (United Network for Organ Sharing criteria). For female patients, the number of pretransplant pregnancies was an additional risk factor. Recurrent UTI was observed in 44% of patients from the UTI group. The most common infectious agents were Escherichia coli and Klebsiella pneumoniae, for both isolated and recurrent UTI. No difference in renal graft function or immunosuppressive therapy was observed between groups after the 1-year follow-up. CONCLUSIONS: In this series, older age, previous pregnancy, kidneys from expanded criteria donors, and biopsy-proven acute rejection episodes were risk factors for posttransplant UTI. Recurrence of UTI was observed in 44%, with no negative impact on graft function or survival.
Assuntos
Infecções por Escherichia coli/etiologia , Transplante de Rim , Infecções por Klebsiella/etiologia , Klebsiella pneumoniae , Complicações Pós-Operatórias/etiologia , Infecções Urinárias/etiologia , Adulto , Infecções por Escherichia coli/epidemiologia , Feminino , Sobrevivência de Enxerto , Humanos , Incidência , Infecções por Klebsiella/epidemiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Recidiva , Estudos Retrospectivos , Fatores de Risco , Infecções Urinárias/epidemiologiaRESUMO
INTRODUCTION: The organ shortage for transplantation, the principal factor that increases waiting lists, has become a serious public health problem. In this scenario, the intensivist occupies a prominent position as one of the professionals that first has a chance to identify brain death and to be responsible for the maintenance of the potential deceased donor. OBJECTIVE: This report attempts to establish guidelines for care and maintenance of adult deceased donor organs guiding and standardizing care provided to patients with brain death. METHOD: These guidelines were composed by intensivists, transplant coordinators, professionals from various transplant teams, and used transplant center. The formulated questions were forwarded to all members and recommendations were constructed after an extensive literature review selecting articles with the highest degree of evidence. RESULTS: Guidelines were developed in the form of questions reflecting frequent experiences in clinical intensive care practices. The main questions were: Is there an optimal interval for keeping organs of deceased donors viable? What actions are considered essential for maintaining deceased donors in this period? What are the limits of body temperature? How should the patient be warmed? Which laboratory tests should be performed? What is the collection interval? What are the limits in the laboratory and the capture scenario? What are the limits of blood pressure? When and how should one use catecholamines? CONCLUSIONS: This pioneer project involved a multidisciplinary team working in organ transplantation seeking to provide treatment guidance to increase the number of viable organs from deceased adult donors.
Assuntos
Morte Encefálica , Cuidados Críticos/normas , Transplante de Órgãos/normas , Doadores de Tecidos/provisão & distribuição , Coleta de Tecidos e Órgãos/normas , Obtenção de Tecidos e Órgãos/normas , Adulto , Biomarcadores/sangue , Pressão Sanguínea , Determinação da Pressão Arterial/normas , Volume Sanguíneo , Temperatura Corporal , Morte Encefálica/sangue , Morte Encefálica/diagnóstico , Morte Encefálica/fisiopatologia , Brasil , Dióxido de Carbono/sangue , Cardiotônicos/uso terapêutico , Ecocardiografia/normas , Transfusão de Eritrócitos/normas , Medicina Baseada em Evidências , Hidratação/normas , Humanos , Pressão Intracraniana , Ácido Láctico/sangue , Oxigênio/sangue , Reaquecimento/normas , Fatores de Tempo , Sobrevivência de Tecidos , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: Conversion to sirolimus (SRL)-based immunosuppression in renal transplant recipients is an alternative for chronic allograft dysfunction (CAD), cancer and viral infections. We sought to analyze the indications for and safety and efficacy of conversion to SRL among renal transplant patients. METHODS/MATERIALS: We examined a retrospective cohort, using medical records of renal transplant recipients >18 years old who had their immunosuppressive regimen converted to a SRL-based treatment. Data analysis included the indication for conversion, time posttransplant, as well as urine protein and serum creatinine at conversion and 6 months thereafter. The end points included death, graft loss and/or discontinuation of SRL. RESULTS: We included 112 patients in this series who had indications for conversion: fungal, polyomavirus, or cytomegalovirus infection (n = 32), CAD (n = 30), cancer (n = 21), immunologic (n = 3), and other reasons (n = 26). Changes in immunosuppression were performed at 41 ± 57 months posttransplant or later in cancer patients. SRL was discontinued in 9 patients owing to adverse events such as edema, proteinuria, mucositis, or pneumonitis. Graft loss was observed in 19 patients, and death in 6. In 87 patients with functioning grafts, protein/creatinine ratios increased from 0.28 ± 0.03 (conversion) to 0.63 ± 0.09 (after 6 months; P < .001). Serum creatinine decreased from 2.24 ± 0.13 (conversion) to 1.89 ± 0.75 mg/dL (after 6 months; P < .001). Graft survival was 88% at 1 and 80% at 3 years after conversion. CONCLUSION: In, SRL was well tolerated; conversion to SRL improved graft function with a slight increase in proteinuria.
Assuntos
Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/efeitos dos fármacos , Imunossupressores/administração & dosagem , Transplante de Rim/imunologia , Sirolimo/administração & dosagem , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Creatinina/sangue , Substituição de Medicamentos , Rejeição de Enxerto/sangue , Rejeição de Enxerto/imunologia , Humanos , Imunossupressores/efeitos adversos , Estimativa de Kaplan-Meier , Transplante de Rim/efeitos adversos , Proteinúria/etiologia , Proteinúria/prevenção & controle , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sirolimo/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: After renal transplantation recovery in nutritional status occurs during the first year. We assessed the changes in nutritional status after transplantation in 145 transplant recipients (94 males, 51 females). METHODS: Patients were evaluated immediately after renal transplant (baseline data) and at 6 months' follow-up. Analysis included body mass index (BMI), body composition (skin fold and arm circumference), and estimated body composition (calculated percent of fat, arm circumference, arm muscle circumference, and arm muscle area). Other data obtained from medical records included renal function (MDRD) serum albumin and lipid profile. RESULTS: At baseline evaluation (21 ± 15 days posttransplant), mean BMI was 23.9 ± 3.9 kg/m(2), serum albumin was 3.7 ± 0.7 g/dL, and lipid profile showed (cholesterol 158.5 ± 52.7 mg% and triglycerides 135.9 ± 91.8 mg%. Body composition analysis showed better adaptation of muscle mass in females [AC (91 ± 10.2 × 98 ± 14.6; male × female, P < .05) arm muscle circumference (92.6 ± 1.4 × 102.3% ± 2.9%, male × female, P < .05) and arm muscle area (87.1 ± 22.3 × 105.5% ± 25.9%, male × female, P < .05)]. Body fat was above the recommended levels in 80% of patients, especially females. After 6 months we divided the groups according to BMI, observing better renal function in the normal weight group compared with obese subjects (60 ± 17.2 × 39.5 ± 19.8 mL/min MDRD, P < .05), despite comparable estimated glomerular filtration rate at baseline. CONCLUSION: The nutritional assessment of patients with end-stage renal disease early after renal transplantation, showed inadequate body composition, with increased fat and reduced lean body mass. The lower glomerular filtration rate after 6 months may be attributed to relatively inadequate renal mass or to obesity-induced hyperfiltration.
Assuntos
Composição Corporal , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Estado Nutricional , Obesidade/diagnóstico , Adiposidade , Adulto , Biomarcadores/sangue , Índice de Massa Corporal , Brasil/epidemiologia , Feminino , Taxa de Filtração Glomerular , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/fisiopatologia , Lipídeos/sangue , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Obesidade/sangue , Obesidade/epidemiologia , Obesidade/fisiopatologia , Prevalência , Estudos Prospectivos , Albumina Sérica/metabolismo , Albumina Sérica Humana , Dobras Cutâneas , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Polyomavirus BK (BKV) is currently considered one of the most important infectious diseases in kidney transplants recipients. The prevalence of decoy cells (viral containing shed urothelial cells) in these patients varies between 20% and 60%. Of decoy-positive patients, 1%-8% develop BKV nephropathy, a finding that may be associated with graft failure in up to 80% of affected individuals. METHODS: Decoy cells cytology is an easily performed and inexpensive assay useful for poliomavirus infection screening. Data on the prevalence of decoy cells in simultaneous pancreas-kidney or isolated pancreas recipients remains largely unreported. In the present study, we evaluated 221 patients ≥18 years old with >1 month follow-up after transplantation who had attended the outpatient clinic between September and December 2006. RESULTS: The total prevalence of decoy cells was 16% (16.9% in kidney recipients, 5.9% in simultaneous kidney-pancreas recipients and 20% in pancreas alone recipients). There were no differences between patients with either positive or negative urinary cytology for decoy cells, regarding demographic (gender, age, race) or clinical (time posttransplantation, donor type [deceased vs living donation], and presence of delayed graft function or rejection, other associated viral infections and type of immunosuppressive drugs variables.
Assuntos
Vírus BK/isolamento & purificação , Transplante de Rim/efeitos adversos , Transplante de Pâncreas/efeitos adversos , Infecções por Polyomavirus/diagnóstico , Infecções Tumorais por Vírus/diagnóstico , Urotélio/virologia , Adolescente , Adulto , Idoso , Brasil , Estudos Transversais , Função Retardada do Enxerto/virologia , Feminino , Rejeição de Enxerto/virologia , Humanos , Imunossupressores/efeitos adversos , Masculino , Pessoa de Meia-Idade , Infecções por Polyomavirus/epidemiologia , Infecções por Polyomavirus/urina , Infecções por Polyomavirus/virologia , Valor Preditivo dos Testes , Prevalência , Fatores de Tempo , Resultado do Tratamento , Infecções Tumorais por Vírus/epidemiologia , Infecções Tumorais por Vírus/urina , Infecções Tumorais por Vírus/virologia , Urinálise , Urina/citologia , Urina/virologia , Adulto JovemRESUMO
INTRODUCTION: Renal insufficiency can be associated with poor long-term survival of liver transplant recipients. OBJECTIVE: The objective of this study was to study renal insufficiency observed pretransplantation and its long-term impact after liver transplantation. METHODS: We analyzed retrospectively an electronic database collected prospectively including transplant records from June 1994 to October 2010 using piggyback venous reconstruction. The exclusion criteria were chronic kidney disease, acute hepatic failure, children up to 12 years of age, and retransplantations. Renal insufficiency was defined by the creatinine clearance (CCr) calculated using the Cockcroft-Gault method. Patients were distributed into 3 groups: CCr >90, between 90 and 60, and >60 mL/min/1.73 m(2). The survival rate was calculated using the Kaplan-Meier method and proportional hazards Cox regression analysis using death and CCr as stratifying variables evaluated predictive factors for survival. The groups were compared using the Kruskal-Wallis test with significant differences at P < .05. RESULTS: Among the 305 patients those who showed preoperative and postoperative CCR of >90 were 187/59.9% and 82/26.3%, 60 to 90 were 77/24.7% and 74/23.7%, or <60 mL/min/1.73 m(2) were (41/13.1% and 149 (47.7%). Patients with preoperative CCr <60 mL/min/1.73 m(2) showed worse short- and long-term survivals as well as the longest intensive care unit and hospital stays (P = .034). The only predictive donor factor was age older than 40 years namely, the greatest hemotransfusion needs and postoperative liver and renal dysfunction (Chi square = 100.6064; P = .00001). The area under the curve (AUC) obtained using an receiver operating characteristic (ROC) analysis was 0.563 (95% CI 0.498-0.627) with a cut off of 30.25. CONCLUSION: Pre-liver transplantation renal insufficiency seemed to be a predictive factor for long-term survival.
Assuntos
Creatinina/sangue , Hepatopatias/cirurgia , Transplante de Fígado/mortalidade , Insuficiência Renal/diagnóstico , Adulto , Fatores Etários , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Feminino , Humanos , Estimativa de Kaplan-Meier , Testes de Função Renal , Hepatopatias/complicações , Hepatopatias/mortalidade , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Curva ROC , Insuficiência Renal/sangue , Insuficiência Renal/complicações , Insuficiência Renal/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
UNLABELLED: Delayed graft function (DGF), a frequent complication after kidney transplantation, occurs among about 60% of recipients of kidneys from deceased donors. DGF has a multifactorial etiology. It is characterized by acute tubular necrosis (ATN) upon biopsy. In this study we sought to identify among a group of recipients of kidneys from deceased donors, the incidence, risk factors, and impacts on patient and graft survivals of DGF. MATERIALS AND METHODS: We retrospectively analyzed medical records from renal transplant recipients aged >18 years who received a deceased donor kidney graft between January 2003 and December 2006. Kidneys lost during the first week posttransplantation were excluded from this series. RESULTS: Among 165 transplants, 111 (67%) displayed DGF, defined as the need for dialysis during the first week posttransplantation. The incidence of DGF was higher among patients with a cold ischemia time (CIT) > 24 hours: 85% vs 60%, DGF vs no DGF (P < .05), as well as for grafts from older donors. After 1-year follow-up, the DGF group showed worse graft function (serum creatinine 1.6 +/- 0.7 vs 1.3 +/- 0.4 mg/dL; P < .05) as well as a greater incidence of graft loss. CONCLUSION: Prolonged cold ischemia and older donor age were associated with a greater incidence of DGF in this series, leading to prolonged hospitalization, increased risk for an acute rejection episode, and reduced graft function and survival after 1 year.