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David-Neto E, Filho MPM, de Sá ÍJAS, Agena F, de Andrade JL, de Paula FJ. The impact of mTOR inhibitors in the regression of left ventricular hypertrophy in elderly kidney transplant recipients. Clin Transplant 2022; 36:e14742. [PMID: 35678134 DOI: 10.1111/ctr.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/24/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
End-stage kidney disease is frequently associated with left ventricular hypertrophy (LVH), a condition more prevalent in the elderly, that may increase mortality after renal transplantation (RTx). Previous studies suggested that mTOR inhibitors (mTORi) can improve LVH, but this has never been tested in elderly kidney transplant recipients. In this prospective randomized clinical trial, we analyzed the impact of Everolimus (EVL) on the reversal of LVH after RTx in elderly recipients (≥60 years) submitted to different immunosuppressive regimens: EVL/lowTacrolimus (EVL group, n = 53) or mycophenolate sodium/regularTacrolimus (MPS group, n = 47). Patients performed echocardiograms (Echo) up to 3 months after RTx and then annually. At baseline, mean age was 65±3 years in both groups and LVH was observed in 63.6% of patients in EVL group and in 61.8% of MPS group. Last Echo was performed at mean time of 47 and 49 months after RTx in EVL and MPS groups, respectively (P = .34). LVH regression was observed in 23.8% (EVL group) and 19% (MPS group) of patients (P = 1.00). Mean eGFR, blood pressure, and use of RAS blockers were similar between groups throughout follow-up. EVL did not improve LVH in this cohort, and this lack of benefit may be attributed to concomitant use of TAC, senescence, or both.
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Affiliation(s)
- Elias David-Neto
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marcelo Paes Menezes Filho
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Fabiana Agena
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - José Lázaro de Andrade
- Echochardiographic Service of the Image and Radiology Institute, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flávio Jota de Paula
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Quinino RME, Agena F, Paula FJD, Nahas WC, David-Neto E. Comparative analysis of kidney transplant costs related to recovery of renal function after the procedure. ACTA ACUST UNITED AC 2021; 43:375-382. [PMID: 33899907 PMCID: PMC8428635 DOI: 10.1590/2175-8239-jbn-2020-0172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
Introduction: The number of kidney transplants (KTx) is increasing in Brazil and,
consequently, the costs of this procedure increase the country's health
budget. We retrospectively evaluated the data of kidney transplant
procedures until hospital discharge, according to kidney function recovery
after the procedure. Methods: Retrospective analysis of the non-sensitized, 1st KTx from deceased donors
performed between Jan/2010 to Dec/2017. Results: Out of the 1300 KTx from deceased donors performed in this period, 730
patients were studied and divided into 3 groups: Immediate Renal Function
(IRF) - decrease in serum creatinine ≥ 10% on two consecutive days; Delayed
Graft Function (DGF) - decrease in serum creatinine <10% on two
consecutive days, without the need for dialysis, and Dialysis (D) - need for
dialysis during the first week. Patients in group D stayed longer in the
hospital compared to DGF and IRF (21, 11 and 8 days respectively, p <
0.001). More D patients (21%) were admitted to the ICU and performed a
greater number of laboratory tests (p < 0.001) and renal biopsies (p <
0.001), in addition to receiving a higher amount of immunosuppressants.
Total hospital costs were higher in group D and DGF compared to IRF (U$
7.021,48; U$ 3.603,42 and U$ 2.642,37 respectively, p < 0.001). Conclusion: The costs of the transplant procedure is impacted by the recovery of kidney
function after the transplant. The reimbursement for each of these different
kidney function outcomes should be individualized in order to cover their
real costs.
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Affiliation(s)
- Raquel Martins E Quinino
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Transplante Renal, São Paulo, SP, Brasil
| | - Fabiana Agena
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Transplante Renal, São Paulo, SP, Brasil
| | - Flávio Jota de Paula
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Transplante Renal, São Paulo, SP, Brasil
| | - William Carlos Nahas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Transplante Renal, São Paulo, SP, Brasil
| | - Elias David-Neto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Transplante Renal, São Paulo, SP, Brasil
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Vieira AP, Trindade MAB, de Paula FJ, Sakai-Valente NY, Duarte AJDS, Lemos FBC, Benard G. Severe type 1 upgrading leprosy reaction in a renal transplant recipient: a paradoxical manifestation associated with deficiency of antigen-specific regulatory T-cells? BMC Infect Dis 2017; 17:305. [PMID: 28438129 PMCID: PMC5404339 DOI: 10.1186/s12879-017-2406-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/13/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Due to its chronic subclinical course and large spectrum of manifestations, leprosy often represents a diagnostic challenge. Even with proper anti-mycobacteria treatment, leprosy follow up remains challenging: almost half of leprosy patients may develop reaction episodes. Leprosy is an infrequent complication of solid organ transplant recipients. This case report illustrates the challenges in diagnosing and managing leprosy and its reactional states in a transplant recipient. CASE PRESENTATION A 53-year-old man presented 34 months after a successful renal transplantation a borderline-tuberculoid leprosy with signs of mild type 1 upgrading reaction (T1R). Cutaneous manifestations were atypical, and diagnosis was only made when granulomatous neuritis was found in a cutaneous biopsy. He was successfully treated with the WHO recommended multidrug therapy (MDT: rifampicin, dapsone and clofazimine). However he developed a severe T1R immediately after completion of the MDT but no signs of allograft rejection. T1R results from flare-ups of the host T-helper-1 cell-mediated immune response against Mycobacterium leprae antigens in patients with immunologically unstable, borderline forms of leprosy and has been considered an inflammatory syndrome in many aspects similar to the immune reconstitution inflammatory syndromes (IRS). The T1R was successfully treated by increasing the prednisone dose without modifying the other immunosuppressive drugs used for preventing allograft rejection. Immunological study revealed that the patient had a profound depletion of both in situ and circulating regulatory T-cells and lack of expansion of the Tregs upon M. leprae stimulation compared to T1R leprosy patients without iatrogenic immunosuppression. CONCLUSIONS Our case report highlights that leprosy, especially in the transplant setting, requires a high degree of clinical suspicion and the contribution of histopathology. It also suggests that the development of upgrading inflammatory syndromes such as T1R can occur despite the sustained immunosuppressors regimen for preventing graft rejection. Our hypothesis is that the well-known deleterious effects of these immunosuppressors on pathogen-induced regulatory T-cells contributed to the immunedysregulation and development T1R.
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Affiliation(s)
- Ana Paula Vieira
- Laboratory of Medical Investigation Unit 56, Division of Clinical Dermatology, Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Flávio Jota de Paula
- Renal Transplantation Service, Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Neusa Yurico Sakai-Valente
- Laboratory of Medical Investigation Unit 53, Tropical Medicine Institute, University of São Paulo, São Paulo, Brazil
| | - Alberto José da Silva Duarte
- Laboratory of Medical Investigation Unit 56, Division of Clinical Dermatology, Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Gil Benard
- Laboratory of Medical Investigation Unit 56, Division of Clinical Dermatology, Medical School, University of São Paulo, São Paulo, Brazil. .,Laboratory of Medical Investigation Unit 53, Tropical Medicine Institute, University of São Paulo, São Paulo, Brazil.
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Paula FJD, Neves PDMDM, Bridi RA, Song ATW, David-Neto E. First Report of Granulicatella sp. Endocarditis in a Kidney Transplant
Patient. J Bras Nefrol 2017; 39:341-344. [DOI: 10.5935/0101-2800.20170059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/16/2017] [Indexed: 11/20/2022] Open
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Silva RT, Martinelli Filho M, Peixoto GDL, Lima JJGD, Siqueira SFD, Costa R, Gowdak LHW, Paula FJD, Kalil Filho R, Ramires JAF. Predictors of Arrhythmic Events Detected by Implantable Loop Recorders in Renal Transplant Candidates. Arq Bras Cardiol 2015; 105:493-502. [PMID: 26351983 PMCID: PMC4651408 DOI: 10.5935/abc.20150106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 06/01/2015] [Indexed: 12/03/2022] Open
Abstract
Background The recording of arrhythmic events (AE) in renal transplant candidates (RTCs)
undergoing dialysis is limited by conventional electrocardiography. However,
continuous cardiac rhythm monitoring seems to be more appropriate due to automatic
detection of arrhythmia, but this method has not been used. Objective We aimed to investigate the incidence and predictors of AE in RTCs using an
implantable loop recorder (ILR). Methods A prospective observational study conducted from June 2009 to January 2011
included 100 consecutive ambulatory RTCs who underwent ILR and were followed-up
for at least 1 year. Multivariate logistic regression was applied to define
predictors of AE. Results During a mean follow-up of 424 ± 127 days, AE could be detected in 98% of
patients, and 92% had more than one type of arrhythmia, with most considered
potentially not serious. Sustained atrial tachycardia and atrial fibrillation
occurred in 7% and 13% of patients, respectively, and bradyarrhythmia and
non-sustained or sustained ventricular tachycardia (VT) occurred in 25% and 57%,
respectively. There were 18 deaths, of which 7 were sudden cardiac events: 3
bradyarrhythmias, 1 ventricular fibrillation, 1 myocardial infarction, and 2
undetermined. The presence of a long QTc (odds ratio [OR] = 7.28; 95% confidence
interval [CI], 2.01–26.35; p = 0.002), and the duration of the PR interval (OR =
1.05; 95% CI, 1.02–1.08; p < 0.001) were independently associated with
bradyarrhythmias. Left ventricular dilatation (LVD) was independently associated
with non-sustained VT (OR = 2.83; 95% CI, 1.01–7.96; p = 0.041). Conclusions In medium-term follow-up of RTCs, ILR helped detect a high incidence of AE, most
of which did not have clinical relevance. The PR interval and presence of long QTc
were predictive of bradyarrhythmias, whereas LVD was predictive of non-sustained
VT.
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Affiliation(s)
- Rodrigo Tavares Silva
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Giselle de Lima Peixoto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Roberto Costa
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Flávio Jota de Paula
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Gowdak LHW, de Paula FJ, César LAM, Bortolotto LA, de Lima JJG. A new risk score model to predict the presence of significant coronary artery disease in renal transplant candidates. Transplant Res 2013; 2:18. [PMID: 24176034 PMCID: PMC3892004 DOI: 10.1186/2047-1440-2-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 10/01/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Renal transplant candidates are at high risk of coronary artery disease (CAD). We sought to develop a new risk score model to determine the pre-test probability of the occurrence of significant CAD in renal transplant candidates. METHODS A total of 1,060 renal transplant candidates underwent a comprehensive cardiovascular risk evaluation. Patients considered at high risk of CAD (age ≥50 years, with either diabetes mellitus (DM) or cardiovascular disease (CVD)), or having noninvasive testing suggestive of CAD were referred for coronary angiography (n = 524). Significant CAD was defined by the presence of luminal stenosis ≥70%. A binary logistic regression model was built, and the resulting logistic regression coefficient B for each variable was multiplied by 10 and rounded to the next whole number. For each patient, a corresponding risk score was calculated and the receiver operating characteristic (ROC) curve was constructed. RESULTS The final equation for the model was risk score = (age × 0.4) + (DM × 9) + (CVD × 14) and for the probability of CAD (%) = (risk score × 2) - 23. The corresponding ROC for the accuracy of the diagnosis of CAD was 0.75 (P <0.0001) in the developmental model. CONCLUSIONS We developed a simple clinical risk score to determine the pre-test probability of significant CAD in renal transplant candidates. This model may help those directly involved in the care of patients with end-stage renal disease being considered for transplantation in an attempt to reduce the rate of cardiovascular events that presently hampers the long-term prognosis of such patients.
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Affiliation(s)
- Luís Henrique Wolff Gowdak
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 44, São Paulo 05403-000, Brazil
| | - Flávio Jota de Paula
- Renal Transplant Unit, Hospital das Clínicas, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 255, São Paulo 05403-000, Brazil
| | - Luiz Antônio Machado César
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 44, São Paulo 05403-000, Brazil
| | - Luiz Aparecido Bortolotto
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 44, São Paulo 05403-000, Brazil
| | - José Jayme Galvão de Lima
- Heart Institute (InCor), Hospital das Clínicas, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 44, São Paulo 05403-000, Brazil
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Marques IDB, Caires RA, de Paula FJ, Nahas WC, David-Neto E. Rejection-triggered haemophagocytic syndrome in renal transplantation successfully treated with intravenous immunoglobulin. Clin Kidney J 2013; 6:530-2. [PMID: 26064519 PMCID: PMC4438393 DOI: 10.1093/ckj/sft077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/14/2013] [Indexed: 11/12/2022] Open
Abstract
Haemophagocytic syndrome (HPS) is a rare and potentially lethal condition characterized by pancytopoenia, fever, organomegaly and widespread proliferation of macrophages phagocytosing blood elements. Among the triggers of this syndrome, excessive immunosuppression in a context of acute rejection has been rarely reported, although it might be underdiagnosed. Here, we report the case of a kidney transplant recipient with allograft dysfunction due to chronic antibody-mediated rejection treated with antithymocyte globulin and plasmapheresis. The patient developed high fever, pancytopoenia, diarrhoea and respiratory symptoms with no apparent infectious or neoplastic cause, despite an extensive work-up. Haemophagocytosis was found in bone marrow examination, along with hyperferritinaemia and hypertriglyceridaemia. The clinical profile improved after treatment with intravenous immunoglobulin and reduction of the basal immunosuppression.
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Affiliation(s)
| | - Renato Antunes Caires
- Nephrology Division , Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
| | - Flávio Jota de Paula
- Renal Transplant Service , Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
| | - William Carlos Nahas
- Renal Transplant Service , Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
| | - Elias David-Neto
- Renal Transplant Service , Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
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De Lima JJG, Gowdak LHW, de Paula FJ, César LAM, Ramires JAF, Bortolotto LA. Which patients are more likely to benefit from renal transplantation? Clin Transplant 2012; 26:820-5. [DOI: 10.1111/j.1399-0012.2012.01631.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2011] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Flávio Jota de Paula
- Renal Transplant Unit, Division of Urology; Hospital das Clínicas, University of São Paulo Medical School; São Paulo; Brazil
| | | | | | - Luiz A. Bortolotto
- Heart Institute (InCor); University of São Paulo Medical School; São Paulo; Brazil
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Galvão De Lima JJ, Wolff Gowdak LH, de Paula FJ, Franchini Ramires JA, Bortolotto LA. The role of myocardial scintigraphy in the assessment of cardiovascular risk in patients with end-stage chronic kidney disease on the waiting list for renal transplantation. Nephrol Dial Transplant 2012; 27:2979-84. [DOI: 10.1093/ndt/gfr770] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ferreira GF, Marques IDB, Park CHL, Machado DJDB, Lemos FBC, Paula FJD, Nahas WC, David-Neto E. Análise de 10 anos de seguimento de transplantesrenais com doador vivo não aparentado. J Bras Nefrol 2011; 33:345-50. [DOI: 10.1590/s0101-28002011000300011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 08/04/2011] [Indexed: 11/22/2022] Open
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Feitosa ACR, Marques AC, Caramelli B, Ayub B, Polanczyk CA, Jardim C, Vieira CLZ, Pinho C, Calderaro D, Gualandro DM, Iezzi D, Ikeoka DT, Schreen D, D'Amico EA, Pfeferman E, Lima EQD, Burdmann EDA, Pachon E, Machado FS, Galas FRBG, Paula FJD, Carvalho FCD, Feitosa-Filho GS, Prado GF, Lopes HF, Lima JJGD, Marchini JFM, Fornari LS, Drager LF, Vacanti LJ, Hajjar LA, Rohde LEP, Gowdak LH, Cardoso LF, Vieira MLC, Monachini MC, Macatrão M, Yu PC, Villaça PR, Farsky PS, Lopes RD, Bagnatori RS, Heinisch RH, Gualandro SFM, Accorsi TAD, Ávila WS, Mathias Jr. W. II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia. Arq Bras Cardiol 2011. [DOI: 10.1590/s0066-782x2011000800001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Gualandro DM, Yu PC, Calderaro D, Marques AC, Pinho C, Caramelli B, Feitosa ACR, Ayub B, Polanczyk CA, Jardim C, Vieira CLZ, lezzi D, Ikeoka DT, Schreen D, D'Amico EA, Pfeferman E, de Lima EQ, Burdmann EDA, Pachon E, Machado FS, Galas FRBG, Paula FJD, Carvalho FCD, Feitosa-Filho GS, Prado GF, Lopes HF, Lima JJGD, Marchini JFM, Fornari LS, Drager LF, Vacanti LJ, Hajjar LA, Rohde LEP, Gowdak LH, Cardoso LF, Vieira MLC, Monachini MC, Macatrão M, Villaça PR, Farsky PS, Lopes RD, Bagnatori RS, Heinisch RH, Gualandro SFM, Accorsi TAD, Avila WS, Mathias W. II Guidelines for perioperative evaluation of the Brazilian Society of Cardiology. Arq Bras Cardiol 2011; 96:1-68. [PMID: 21655875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Affiliation(s)
- Danielle Menosi Gualandro
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - andar AB - bloco 2, setor C6, 05403-000 São Paulo
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Gowdak LHW, Arantes RL, de Paula FJ, Krieger EM, De Lima JJG. Underuse of American College of Cardiology/American Heart Association Guidelines in hemodialysis patients. Ren Fail 2007; 29:559-65. [PMID: 17654318 DOI: 10.1080/08860220701395002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Patients with end-stage renal disease (ESRD) are at high risk for cardiovascular disease (CVD) and therefore should be treated according to ACC/AHA Guidelines. Scant data are available concerning the actual use of cardioprotective drugs in this population. The use of angiotensin-converting enzyme inhibitors (ACE-I), beta-blockers, aspirin, and statins was assessed in 271 (72% males, 66% Caucasians) high-risk ESRD patients on hemodialysis. The study population comprised 27% smokers, 95% with hypertension, 38% with diabetes, and 44% with dyslipidemia; 44% of patients had overt CVD at baseline, including 9% with heart failure, 9% with prior myocardial infarction, and 3% with previous myocardial revascularization. One-third of all patients were not receiving any cardioprotective drugs; among those patients who were, 42% were on one drug, 21% were on two, 3.7% were on three, and 1.5% were on four. The most prescribed agent was ACE-I (35.8%), followed by aspirin (30.6%), and beta-blockers (28.0%). The use of statins was remarkably and significantly low (4.1%) (p < 0.001), even in the higher risk subgroups (patients with diabetes or macrovascular disease). ACE-I plus aspirin was the most prescribed combination (8.5%). Cardioprotective agents recommended for risk-factor modification by the ACC/AHA Guidelines for their well-established efficacy in the general population were underutilized in this cohort of high-risk hypertensive hemodialysis patients, despite an elevated prevalence of clinically evident CVD. Speculatively, this fact may be relevant to better understand the known increased cardiovascular morbidity-mortality associated with chronic renal disease.
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Gowdak LHW, de Paula FJ, César LAM, Filho EEM, Ianhez LE, Krieger EM, Ramires JAF, De Lima JJG. Diabetes and coronary artery disease impose similar cardiovascular morbidity and mortality on renal transplant candidates. Nephrol Dial Transplant 2007; 22:1456-61. [PMID: 17267536 DOI: 10.1093/ndt/gfl781] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In renal transplant candidates (RTC), diabetes and coronary artery disease (CAD) are commonly observed. However, whether diabetes imparts a cardiovascular risk equivalent to that of CAD and whether CAD adds to the cardiovascular risk associated with diabetes is unknown. METHODS To assess the interplay between diabetes and CAD as a determinant of major adverse cardiovascular events (MACE), 288 high-risk RTC (56.4+/-8.1 years old, 72% males) underwent a comprehensive cardiovascular evaluation including coronary angiography. Patients were divided into four groups based on the diagnoses of diabetes and CAD (>70% narrowing), and followed up for 1-60 months (median, 17). The primary endpoint was the composite incidence of fatal/non-fatal MACE. RESULTS During follow-up, 80 MACE occurred. Patients with diabetes (P=0.03) or CAD (P<0.0001) had a worse long-term prognosis. However, only in patients without diabetes was CAD associated with an increased incidence of MACE (10.6% vs 45.9%, P<0.0001). In patients with diabetes, the endpoints were not different between those with and without CAD. No difference occurred in the long-term prognosis of patients with diabetes (with or without CAD) and patients without diabetes with CAD. CONCLUSIONS We concluded that in high-risk RTC, diabetes confers a cardiovascular risk comparable to that of CAD in patients without diabetes, independent of coronary obstruction. In patients with diabetes, concomitant CAD does not add to the already very high cardiovascular risk of this population.
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Affiliation(s)
- Luís Henrique Wolff Gowdak
- Heart Institute (InCor), University of São Paulo Medical School, and Renal Transplant Unit, Hospital das Clínicas, SP-Brazil.
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Gowdak LHW, Paula FJD, Giorgi DMA, Vieira MLC, Krieger EM, Lima JJGD. Doença cardiovascular e fatores de risco cardiovascular em candidatos a transplante renal. Arq Bras Cardiol 2005; 84:156-60. [PMID: 15761640 DOI: 10.1590/s0066-782x2005000200012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine the prevalence of cardiovascular disease (CVD) and traditional risk factors in patients with chronic renal failure undergoing evaluation for inclusion on the renal transplantation list. METHODS One hundred ninety-five patients with dialytic chronic renal failure underwent clinical evaluation and complementary tests and were compared with a group of 334 hypertensive patients paired for age. The Framingham equations were used for calculating the absolute risk (AR). The relative risk (RR) was calculated based on the absolute risk of the low-risk Framingham cohort. RESULTS Thirty-seven percent of the patients had some sort of cardiovascular disease on the initial evaluation, peripheral vascular disease (23%) being the most prevalent. Patients with cardiovascular disease were excluded. Regarding traditional risk factors, a significant difference was observed in systolic blood pressure and total cholesterol (greater in the hypertensive group), and in the prevalence of men, diabetes, and smoking, which were greater in the chronic renal failure group. The latter had a greater degree of left ventricular hypertrophy, lower diastolic blood pressure, and a lower prevalence of familial history of cardiovascular disease and obesity. The relative risk for cardiovascular disease in patients with chronic renal failure was greater compared with that in the Framingham control population, but it did not differ from that observed in the group of hypertensive individuals. CONCLUSION The prevalence of cardiovascular disease and traditional risk factors is high among candidates for renal transplantation; the Framingham equations do not adequately quantify the real cardiovascular risk, and other risk factors specific for that population should contribute for their greater cardiovascular risk.
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