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Custodio LDFP, Martins SBS, Viana LA, Cristelli MP, Requião-Moura L, Chow CYZ, Camargo SFDN, Nakamura MR, Foresto RD, Tedesco-Silva H, Medina-Pestana J. Efficacy and safety of single-dose anti-thymocyte globulin versus basiliximab induction therapy in pediatric kidney transplant recipients: A retrospective comparative cohort study. Pediatr Transplant 2024; 28:e14713. [PMID: 38553819 DOI: 10.1111/petr.14713] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/11/2024] [Accepted: 01/28/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND This study aimed to compare the efficacy and safety of basiliximab (BAS) versus a single dose of anti-thymocyte globulin (r-ATG) induction therapy in pediatric kidney transplant recipients (KTRs). METHODS This single-center retrospective comparative cohort study included all pediatric KTRs from May 2013 to April 2018 and followed up to 12 months. In the first period, all recipients received BAS, while from May 2016, a single 3 mg/kg dose of r-ATG was instituted. Maintenance therapy consisted of a calcineurin inhibitor plus prednisone plus azathioprine or mycophenolate. RESULTS A total of 227 patients were included (BAS, n = 113; r-ATG, n = 114). The main combination of immunosuppressive drugs was tacrolimus, prednisone, and azathioprine in both groups (87% vs. 88%, p = .718). Patients receiving r-ATG showed superior survival-free of the composite endpoint (acute rejection, graft loss, or death; 76% vs. 61%, p = .003; HR 2.08, 1.29-3.34, p = .003) and lower incidence of biopsy-proven acute rejection (10% vs. 21%, p = .015). There was no difference in the overall incidence of CMV infection (33% vs. 37%, p = .457), PTLD (1% vs. 3%, p = .309), 30-day hospital readmissions (24% vs. 23%, p = .847), and kidney function at 12 months (86 ± 29 vs. 84 ± 30 mL/min/1.73m2, p = .614). CONCLUSIONS These data suggest that induction therapy with a single 3 mg/kg dose of r-ATG is associated with higher efficacy for preventing acute rejection and similar safety profile compared to BAS.
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Affiliation(s)
| | | | | | | | - Lucio Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Alfaro Villanueva LA, Junior RM, Rangel ÉB, Modelli LG, Viana LA, Cristelli MP, Requião-Moura L, Foresto RD, Tedesco-Silva H, Pestana JM. Assessing the influence of graft loss on 4-year patient survival after simultaneous pancreas-kidney transplantation: Kaplan-Meier versus Competing Risk Analysis model. Clin Transplant 2024; 38:e15298. [PMID: 38545918 DOI: 10.1111/ctr.15298] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 02/28/2024] [Accepted: 03/11/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Graft loss increases the risk of patient death after simultaneous pancreas-kidney (SPK) transplantation. The relative risk of each graft failure is complex due to the influence of several competing events. METHODS This retrospective, single-center study compared 4-year patient survival according to the graft status using Kaplan-Meier (KM) and Competing Risk Analysis (CRA). Patient survival was also assessed according to five eras (Era 1: 2001-2003; Era 2: 2004-2006; Era 3: 2007-2009; Era 4: 2010-2012; Era 5: 2012-2015). RESULTS Between 2000 and 2015, 432 SPK transplants were performed. Using KM, patient survival was 86.5% for patients without graft loss (n = 333), 93.4% for patients with pancreas graft loss (n = 46), 43.7% for patients with kidney graft loss (n = 16), and 25.4% for patients with pancreas and kidney graft loss (n = 37). Patient survival was underestimated using KM versus CRA methods in patients with pancreas and kidney graft losses (25.4% vs. 36.2%), respectively. Induction with lymphocyte depleting antibodies was associated with 81% reduced risk (HR.19, 95% CI.38-.98, p = .0048), while delayed kidney function (HR 2.94, 95% CI 1.09-7.95, p = .033) and surgical complications (HR 2.94, 95% CI 1.22-7.08, p = .016) were associated with higher risk of death. Four-year patient survival increased from Era 1 to Era 5 (79% vs. 87.9%, p = .047). CONCLUSION In this cohort of patients, kidney graft loss, with or without pancreas graft loss, was associated with higher mortality after SPK transplantation. Compared to CRA, the KM model underestimated survival only among patients with pancreas and kidney graft losses. Patient survival increased over time.
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Affiliation(s)
| | | | - Érika Bevilaqua Rangel
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Gustavo Modelli
- Division of Nephrology, Department of Internal Medicine, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | | | | | - Lúcio Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Medina Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Toniato de Rezende Freschi J, Cristelli MP, Viana LA, Ficher KN, Nakamura MR, Proença H, Dreige YC, de Marco R, de Lima MG, Foresto RD, Aguiar WF, Medina-Pestana J, Tedesco-Silva H. A Head-to-head Comparison of De Novo Sirolimus or Everolimus Plus Reduced-dose Tacrolimus in Kidney Transplant Recipients: A Prospective and Randomized Trial. Transplantation 2024; 108:261-275. [PMID: 37525373 DOI: 10.1097/tp.0000000000004749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/02/2023]
Abstract
BACKGROUND Mammalian target of rapamycin inhibitors (mTORi), sirolimus (SRL) and everolimus (EVR), have distinct pharmacokinetic/pharmacodynamics properties. There are no studies comparing the efficacy and safety of de novo use of SRL versus EVR in combination with reduced-dose calcineurin inhibitor. METHODS This single-center prospective, randomized study included first kidney transplant recipients receiving a single 3 mg/kg antithymocyte globulin dose, tacrolimus, and prednisone, without cytomegalovirus (CMV) pharmacological prophylaxis. Patients were randomized into 3 groups: SRL, EVR, or mycophenolate sodium (MPS). Doses of SRL and EVR were adjusted to maintain whole blood concentrations between 4 and 8 ng/mL. The primary endpoint was the 12-mo incidence of the first CMV infection/disease. RESULTS There were 266 patients (SRL, n = 86; EVR, n = 90; MPS, n = 90). The incidence of the first CMV event was lower in the mTORi versus MPS groups (10.5% versus 7.8% versus 43.3%, P < 0.0001). There were no differences in the incidence of BK polyomavirus viremia (8.2% versus 10.1% versus 15.1%, P = 0.360). There were no differences in survival-free from treatment failure (87.8% versus 88.8% versus 93.3%, P = 0.421) and incidence of donor-specific antibodies. At 12 mo, there were no differences in kidney function (75 ± 23 versus 78 ± 24 versus 77 ± 24 mL/min/1.73 m 2 , P = 0.736), proteinuria, and histology in protocol biopsies. Treatment discontinuation was higher among patients receiving SRL or EVR (18.6% versus 15.6% versus 6.7%, P = 0.054). CONCLUSIONS De novo use of SRL or EVR, targeting similar therapeutic blood concentrations, shows comparable efficacy and safety. The reduced incidence of CMV infection/disease and distinct safety profile of mTORi versus mycophenolate were confirmed in this study.
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Affiliation(s)
| | | | | | | | | | | | | | - Renato de Marco
- Immunogenetics Institute, Associação Fundo de Incentivo à Pesquisa, São Paulo, Brazil
| | - Maria Gerbase de Lima
- Immunogenetics Institute, Associação Fundo de Incentivo à Pesquisa, São Paulo, Brazil
| | | | - Wilson Ferreira Aguiar
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Urology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Foresto RD, Hazin MAA, Cassão BC, de Morais APA, Felipe CR, Requião-Moura LR, Medina Pestana J, Tedesco-Silva H. The Association Between Kidney Donor Profile Index and 1-y Graft Function. Transplant Direct 2023; 9:e1476. [PMID: 37090122 PMCID: PMC10118325 DOI: 10.1097/txd.0000000000001476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/23/2023] [Accepted: 02/16/2023] [Indexed: 04/25/2023] Open
Abstract
The association between Kidney Donor Profile Index (KDPI) and 1-y estimated glomerular filtration rate (eGFR) with long-term kidney graft survival is well known. Yet, the association between KDPI and 1-y eGFR remains uncertain considering the several concurrent competing risk factors. Methods This single-center, retrospective cohort study analyzed data from 3059 consecutive deceased donor kidney transplant recipients with a 1-y follow-up from January 2013 to December 2017. The aim was to determine the association between the KDPI strata (0%-35%, 36%-50%, 51%-85%, 86%-100%) and 1-y eGFR estimated by the CKD-EPI equation. Results The incidence of delayed graft function (50.6% versus 59.3% versus 62.7% versus 62.0%; P < 0.001) and cytomegalovirus infection (36.7% versus 36.6% versus 43.3% versus 57.8%; P < 0.001) increased with increasing KDPI strata but not biopsy-proven acute rejection (9.1% versus 9.8% versus 8.4% versus 9.1%; P = 0.736). The median 1-y eGFR decreased with increasing KDPI strata (64.8 versus 53.5 versus 46.9 versus 39.1 mL/min/1.73 m2; P < 0.001). In the Cox regression, the higher the KDPI was, the lower the probability of a lower 1-y eGFR was. Assuming the 0%-35% strata as the reference, the likelihood of eGFR <50 mL/min/1.73 m2 was increased by 76.6% (hazard ratio [HR] = 1.767, 95% confidence interval [CI] = 1.406-2.220), 2.24- and 2.87-fold higher for KDPI higher >35%-50% (HR = 2.239, 95% CI = 1.862-2.691), and >51%-85% (HR = 2.871, 95% CI = 2.361-3.491), respectively. Other variables associated with a lower graft function were donor sex (HR male versus female = 0.896, 95% CI = 0.813-0.989) and cold ischemia time (HR for each hour = 1.011, 95% CI = 1.004-1.019). This association was sustained after the Poisson mediation analysis, including delayed graft function, cytomegalovirus, and acute rejection as mediators. Conclusions In this cohort of deceased donor kidney recipients, KDPI, and cold ischemia time were the major independent risk factors associated with lower 1-y kidney function.
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Affiliation(s)
- Renato Demarchi Foresto
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Maria Amelia Aguiar Hazin
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Bianca Cristina Cassão
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Claudia Rosso Felipe
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Lucio R. Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - José Medina Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Amorim LVP, Cristelli MP, Viana LA, Dreige YC, Requião-Moura LR, Nakamura MR, Foresto RD, Medina-Pestana J, Tedesco-Silva H. Immunogenicity, Reactogenicity, and Reinfection After 2 Doses of the Inactivated Whole-virion CoronaVac Vaccine in Kidney Transplant Recipients Convalescents From COVID-19. Transplantation 2023. [PMID: 36319616 DOI: 10.1097/tp.0000000000004359.10.1097/tp.0000000000004359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- Laysla Verhalen Pouzo Amorim
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Yasmim Cardoso Dreige
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Lucio R Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Monica Rika Nakamura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato Demarchi Foresto
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Helio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Muacevic A, Adler JR, Demarchi Foresto R, Machado Proença H, Medina-Pestana J. Two-Hit Kidney Allograft Injury by SARS-CoV-2. Cureus 2023; 15:e34603. [PMID: 36751573 PMCID: PMC9897707 DOI: 10.7759/cureus.34603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 02/05/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has been associated with acute kidney injury in kidney transplant recipients by several mechanisms. The authors report a case of acute kidney allograft dysfunction in a 48-year-old patient who presented in the emergency room with anasarca and nephrotic syndrome close after mild COVID-19 and no other clinical condition. Histopathology of the allograft biopsy revealed two distinct and simultaneous kidney lesions, collapsing glomerulopathy and thrombotic microangiopathy. Renal function persistently deteriorated, and definitive dialysis was initiated. After excluding other plausible causes for the findings, this case strengthens the hypothesis that the kidney allograft is also a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
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Medina-Pestana J, Covas DT, Viana LA, Dreige YC, Nakamura MR, Lucena EF, Requião-Moura LR, Fortaleza CMCB, Foresto RD, Tedesco-Silva H, Cristelli MP. Inactivated Whole-virus Vaccine Triggers Low Response Against SARS-CoV-2 Infection Among Renal Transplant Patients: Prospective Phase 4 Study Results. Transplantation 2022; 106:853-861. [PMID: 34882589 PMCID: PMC8942595 DOI: 10.1097/tp.0000000000004036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/18/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anti-severe acute respiratory syndrome coronavirus 2 mRNA vaccines elicit lower humoral responses in solid-organ transplant recipients. This is the first prospective trial investigating the effect of an inactivated whole-virion vaccine in kidney transplant recipients. METHODS Prospective, single-center, phase 4, interventional study. Kidney transplant recipients aged 30-69 y with >30 d of transplantation received two 3 µg intramuscular doses of CoronaVac 28 d apart and are being followed for 6 mo. Primary outcomes: (1) reactogenicity after first dose; (2) antibody responses 28 d after each dose; and (3) incidence/severity of confirmed coronavirus disease 2019 (COVID-19) and 28-d lethality rate. For this analysis, clinical effectiveness was assessed for 3 mo, starting 15 d after the second dose, and compared with 3-mo period before vaccination. RESULTS Of the 3371 individuals who received the first dose, 99% completed vaccination schedule. Mild/local adverse reactions were reported by 33% of the patients. In the immunogenicity cohort (n = 942), the proportion of patients with IgG antibodies to severe acute respiratory syndrome coronavirus 2 increased from 15.2% after first dose to 43% after second dose. Increase in antibody values after second dose was associated with higher proportion of patients with detected neutralizing antibodies. A significant reduction in the incidence of COVID-19 was observed (6.4% versus 4.2%; P < 0.0001), although the 28-d lethality rate remained unchanged (25% versus 22%; P = 0.534). In 45 patients from the immunogenicity cohort who developed COVID-19, all the 6 deaths occurred among those without antibody response (n = 22; 49%). CONCLUSIONS CoronaVac vaccine was associated with low reactogenicity, low immunogenicity but reduced incidence of COVID-19 among kidney transplant recipients. The lack of reduction in lethality rates is perhaps associated with the low percentage of patients developing humoral response after the second dose.
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Affiliation(s)
- José Medina-Pestana
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Dimas Tadeu Covas
- Instituto Butantan, São Paulo, Brazil
- Center for Cell-based Therapy (CTC), Regional Blood Center of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Laila Almeida Viana
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Yasmim Cardoso Dreige
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Monica Rika Nakamura
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Elizabeth França Lucena
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Lucio R. Requião-Moura
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Renato Demarchi Foresto
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marina Pontello Cristelli
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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Medina-Pestana J, Abbud-Filho M, Garcia VD, Foresto RD, Requião-Moura LR. Paired kidney donation: are we going beyond reasonable limits in living-donor transplantation? J Bras Nefrol 2022; 44:423-427. [PMID: 35051260 PMCID: PMC9518624 DOI: 10.1590/2175-8239-jbn-2021-0230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 11/21/2022] Open
Abstract
The growing demand for transplant kidneys requires strategies to increase organ supply and avoid long waiting periods on the list. The increase in the number of transplants from living donors involves the growth in the use of unrelated donors and paired kidney donation. Most of these transplants are performed in the USA, where they already represent, respectively, 34% and 16% of total transplants from living donors. In Latin America, and especially in Brazil, there is no collective enthusiasm for these modalities, either at the request of transplanters or that of the community, with the region's priority being to increase transplants from deceased donors, which growth can be up to three-fold. Concerning transplants from matched donors, the possible conflicting results between donors can generate public challenges and they risk compromise the concepts of equal opportunities for transplant candidates, with the possibility of generating resistance to organ donation, especially in regions with socioeconomic limitations and disparities in access to qualified health care and education. This donation model involves challenging ethical and logistical issues, which are subject to questionings, starting with an act of exchange between two pairs until reaching embarrassing proposals, which can compromise the altruistic character of organ donation, and thus not be universally incorporated.
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Affiliation(s)
- José Medina-Pestana
- Fundação Oswaldo Ramos, Hospital do Rim, São Paulo, SP, Brasil.,Universidade Federal de São Paulo, Escola Paulista de Medicina, Disciplina de Nefrologia, São Paulo, SP, Brasil
| | - Mario Abbud-Filho
- Fundação Faculdade Regional de Medicina de São José do Rio Preto, Faculdade de Medicina, Centro de Transplante de Órgãos e Tecidos, Hospital de Base, São José do Rio Preto, SP, Brasil
| | - Valter Duro Garcia
- Centro de Transplante Renal, Santa Casa de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Lúcio R Requião-Moura
- Fundação Oswaldo Ramos, Hospital do Rim, São Paulo, SP, Brasil.,Universidade Federal de São Paulo, Escola Paulista de Medicina, Disciplina de Nefrologia, São Paulo, SP, Brasil
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Kanhouche G, Santos GRF, Orellana HC, Galhardo A, Faccinetto ACB, Barteczko MLM, de Carvalho LSF, Taddeo JB, Foresto RD, Moises VA, Tedesco-Silva H, Pestana JM, Barbosa AHP. Risk factors of transplant renal artery stenosis in kidney transplant recipients. Clinics (Sao Paulo) 2022; 77:100087. [PMID: 35931001 PMCID: PMC9350869 DOI: 10.1016/j.clinsp.2022.100087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/14/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Transplant Renal Artery Stenosis (TRAS) is a recognized vascular complication after kidney transplantation. The overall risk predictors of TRAS are poorly understood. METHODS Retrospective analysis of patients with suspected TRAS (Doppler ultrasound PSV > 200 cm/s) who underwent angiographic study in a single center between 2007 and 2014. All patients with stenosis > 50% were considered with TRAS. Stenosis restricted in the body of the artery was also analyzed in a subgroup. RESULTS 274 patients were submitted to a renal angiography and 166 confirmed TRAS. TRAS group featured an older population (46.3 ± 11.0 vs. 40.9 ±14.2 years; p = 0.001), more frequent hypertensive nephropathy (30.1% vs. 15.7%; p = 0.01), higher incidence of Delayed Graft Function (DGF) (52.0% vs. 25.6%; p < 0.001) and longer Cold Ischemia Time (CIT) (21.5 ± 10.6 vs. 15.7 ± 12.9h; p < 0.001). In multivariable analyses, DGF (OR = 3.31; 95% CI 1.78‒6.30; p < 0.0001) was independent risk factors for TRAS. DM and CIT showed a tendency towards TRAS. The compound discriminatory capacity of the multivariable model (AUC = 0.775; 95% CI 0.718‒0.831) is significantly higher than systolic blood pressure and creatinine alone (AUC = 0.62; 95% CI 0.558-0.661). In body artery stenosis subgroup, DGF (OR = 1.86; 95% CI 1.04‒3.36; p = 0.03) and Diabetes Mellitus (DM) (OR = 2.44; 95% CI 1.31‒4.60; p = 0.005) were independent risk factors for TRAS. CONCLUSION In our transplant population, DGF increased more than 3-fold the risk of TRAS. In the subgroup analysis, both DGF and DM increases the risk of body artery stenosis. The addition of other factors to hypertension and renal dysfunction may increase diagnostic accuracy. TRAS TRIAL REGISTRED: clinicaltrials.gov (n° NCT04225338).
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Affiliation(s)
- Gabriel Kanhouche
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | | | - Henry Campos Orellana
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Attilio Galhardo
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Julia Bernardi Taddeo
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Renato Demarchi Foresto
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Valdir Ambrósio Moises
- Cardiology Division, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - José Medina Pestana
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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10
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Medina-Pestana J, Cristelli MP, Viana LA, Foresto RD, Requião-Moura LR, Tedesco-Silva H, Covas DT. Clinical Impact, Reactogenicity, and Immunogenicity After the First CoronaVac Dose in Kidney Transplant Recipients. Transplantation 2022; 106:e95-e97. [PMID: 34292214 PMCID: PMC8667680 DOI: 10.1097/tp.0000000000003901] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- José Medina-Pestana
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marina Pontello Cristelli
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Laila Almeida Viana
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Renato Demarchi Foresto
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Lucio R. Requião-Moura
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Helio Tedesco-Silva
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Dimas Tadeu Covas
- Instituto Butantan, São Paulo, Brazil
- Center for Cell-based Therapy (CTC), Regional Blood Center of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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11
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Foresto RD, Menezes LM, Nishimura LT, Cristelli MP, Viana LA, Santos DWDCL, Requião-Moura LR, Tedesco-Silva H, Medina-Pestana J. Challenges of Multidrug-resistant New Delhi Metallo-beta-Lactamase (NDM-1)-producing Enterobacteriaceae in Kidney Transplant Patients. J Bras Nefrol 2021; 45:116-120. [PMID: 34694315 PMCID: PMC10139707 DOI: 10.1590/2175-8239-jbn-2021-0033] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 09/08/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The emergence of multidrug-resistant NDM-1-producing enterobacteriaceae strains has become a threat to inpatients, especially to immunosuppressed ones, such as kidney transplant recipients. NDM-1 is a carbapenemase that makes gram-negative bacteria resistant to many types of antibiotics. The incidence of carbapenemase-producing enterobacteria infection in solid organ transplant recipients is around 3 to 10%, with a mortality rate of up to 30%. METHODS We present a case series of 4 patients with NDM-1-producing enterobacteria isolated in urine cultures or rectal swabs. We also conducted a cross-sectional study 30 days after patient identification, collecting surveillance cultures (rectal swab) from all inpatients to assess the extent of spread of this resistance mechanism; a total of 101 patients were included. RESULTS Two patients were adequately treated with negative control cultures. The other two patients were not treated because they were asymptomatic and had subsequent negative urine cultures. No new colonization was identified in the cross-sectional screening, and no new cases of urinary NDM-1 infection were recorded after a 4-year follow-up. CONCLUSION Surveillance for infections caused by multidrug-resistant strains in hospitals treating immunosuppressed patients should be continued and prompt action should be taken in cases of outbreaks of multidrug-resistant infections.
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Affiliation(s)
| | | | | | | | | | | | - Lúcio R Requião-Moura
- Hospital do Rim, São Paulo, SP, Brasil.,Universidade Federal de São Paulo, Divisão de Nefrologia, São Paulo, SP, Brasil
| | - Helio Tedesco-Silva
- Hospital do Rim, São Paulo, SP, Brasil.,Universidade Federal de São Paulo, Divisão de Nefrologia, São Paulo, SP, Brasil
| | - Jose Medina-Pestana
- Hospital do Rim, São Paulo, SP, Brasil.,Universidade Federal de São Paulo, Divisão de Nefrologia, São Paulo, SP, Brasil
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12
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Pestana JM, Cristelli MP, Viana LA, Fernandes RDA, Nakamura MR, Foresto RD, Martins SBS, Santos DWDCL, Aguiar WF, Vaz MLDS. Strategies to keep kidney transplant alive amid the SARS-CoV-2 pandemic. Rev Assoc Med Bras (1992) 2021; 67Suppl 1:63-66. [PMID: 34406296 DOI: 10.1590/1806-9282.67.suppl1.20200766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/20/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study aims to describe the result of the strategies adopted to maintain the transplant program amid the COVID-19 pandemic. METHODS Since March 2020, several measures have been adopted sequentially, including the compulsory use of personal protective equipment and the real-time polymerase chain reaction testing of collaborators, symptomatic patients, potential deceased donors, candidates for recipients, and in-hospital readmissions, regardless of symptoms. The living-donor transplantation was restricted to exceptional cases. RESULTS Among 1013 health professionals, 201 cases of COVID-19 were confirmed between March and August 2020, with no severe cases reported. In this period, we observed a 19% institutional increase in the number of transplants from deceased donors compared with that observed in the same period in 2019. There was no donor-derived severe acute respiratory syndrome virus (SARS-CoV-2) infection. Four COVID-19-positive patients underwent transplantation; after 28 days, all were alive and with functioning allograft. Among the 11,875 already transplanted patients being followed up, there were 546 individuals with confirmed diagnosis, 372 who required hospitalization, and 167 on mechanical ventilation, resulting in a 27% mortality rate. CONCLUSIONS These data confirm that the adoption of sequential and coordinated measures amid the pandemic was able to successfully maintain the transplant program and ensure the safety of health professionals and transplanted patients who were already in follow-up.
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13
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Gonzalez DE, Foresto RD, Maldonado ALS, Padilha WSC, Roberto FB, Pereira MEVDC, Durão Junior MDS, Carvalho AB. Multiple extremity necrosis in fatal calciphylaxis: Case report. ACTA ACUST UNITED AC 2021; 43:274-278. [PMID: 32645129 PMCID: PMC8257280 DOI: 10.1590/2175-8239-jbn-2020-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/07/2020] [Accepted: 05/04/2020] [Indexed: 11/22/2022]
Abstract
Introduction: The clinical impact of vascular calcification is well established in the
context of cardiovascular morbidity and mortality, but other clinical
syndromes, such as calciphylaxis, although less frequent, have a significant
impact on chronic kidney disease. Methods: Case report of a 27-year-old woman, who had complained of bilateral pain in
her toes for 3 days, with the presence of small necrotic areas in the
referred sites. She had a history of type 1 diabetes (25 years ago), with
chronic kidney disease, on peritoneal dialysis, in addition to rheumatoid
arthritis. She was admitted to the hospital, which preceded the current
condition, due to exacerbation of rheumatoid arthritis, evolving with
intracardiac thrombus due to venous catheter complications, when she started
using warfarin. Ischemia progressed to her feet, causing the need for
bilateral amputations. Her chirodactyls were also affected. Thrombophilia,
vasculitis, endocarditis or other embolic sources were investigated and
discarded. Her pathology report evidenced skin necrosis and superficial soft
parts with recent arterial thrombosis, and Monckeberg's medial
calcification. We started treatment with bisphosphonate and sodium
thiosulfate, conversion to hemodialysis and replacement of warfarin with
unfractionated heparin. Despite all the therapy, the patient died after four
months of evolution. Discussion: Calciphylaxis is a rare microvasculature calcification syndrome that results
in severe ischemic injuries. It has pathogenesis related to the mineral and
bone disorder of chronic kidney disease combined with the imbalance between
promoters and inhibitors of vascular calcification, with particular
importance to vitamin K antagonism. Conclusion: The preventive strategy is fundamental, since the therapy is complex with
poorly validated effectiveness.
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Affiliation(s)
- Diego Ennes Gonzalez
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | - Renato Demarchi Foresto
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | - Ana Luiza Santos Maldonado
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | | | - Fernanda Badiani Roberto
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Hospital do Rim, São Paulo, SP, Brasil
| | | | - Marcelino de Souza Durão Junior
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brasil
| | - Aluizio Barbosa Carvalho
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Medicina, São Paulo, SP, Brasil
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14
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Cristelli MP, Viana LA, Fortaleza CM, Granato C, Nakamura MR, Santos DWCL, Foresto RD, Tedesco-Silva H, Medina-Pestana J. Lower seroprevalence for SARS-CoV-2-specific antibodies among kidney transplant recipients compared to the general population in the city of Sao Paulo, Brazil. Transpl Infect Dis 2021; 23:e13706. [PMID: 34322975 PMCID: PMC8420153 DOI: 10.1111/tid.13706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 05/27/2021] [Revised: 07/07/2021] [Accepted: 07/22/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Kidney transplant recipients have higher COVID-19 associated mortality compared to the general population. However, as only symptomatic patients seek medical attention, the current level of exposure, the main sources of acquisition, and the behavior of humoral immunity over time are poorly understood. METHODS This cross-sectional prospective single-center study recruited kidney transplant recipients of any age living in Sao Paulo. A sample size of 401 patients was calculated considering the 17.2% seroprevalence in the municipality population from a published survey, a 95% confidence interval and an absolute error of 2%. RESULTS Of the 2636 eligible patients, 416 were included. The seroprevalence for IgG anti-SARS-CoV-2 was 8.2%. Seroconversion rate decreased with increasing age, from 15.7% (18-35 years) to 8.3% (36-60 years) and 4.2% (>60 years, p = 0.042). Seropositivity among previously confirmed COVID-19 patients was 68.4%, followed by 9.4% in those with flu-like symptoms and only 4.6% among asymptomatic patients (p < 0.0001). Seroprevalence was significantly higher among patients reporting household contact (p = 0.018). Twenty-seven from the 34 IgG+ patients had a second test after 59 (IQR 50-63) days, and, in 33%, the IgG index became below the positivity threshold. CONCLUSIONS In this cohort of kidney transplant recipients, the seroprevalence for IgG anti-SARS-CoV-2 was lower than that of the general population, decreased with ageing, and was associated with household contacts. In a considerable proportion of the patients, there was a significant decay in the IgG levels in a short period of time. Therefore, preventive strategies, such as prioritization for vaccination, should be urgently considered.
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Affiliation(s)
- Marina P Cristelli
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Laila A Viana
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Carlos M Fortaleza
- Infectious Diseases Division, Universidade Estadual Paulista (UNESP), Botucatu, Sao Paulo, Brazil
| | - Celso Granato
- Infectious Diseases Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Monica R Nakamura
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Daniel W C L Santos
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Renato Demarchi Foresto
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Helio Tedesco-Silva
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
| | - Jose Medina-Pestana
- Transplant Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Sao Paulo, Brazil
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15
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Carvalho Fiel D, Nunes Ficher K, Bernardi Taddeo J, Linhares Silva K, Rosso Felipe C, Aguiar W, Daniel Braz Cardone J, Foresto RD, Tedesco-Silva H, Medina-Pestana J. Is There Sufficient Evidence Justifying Limited Access of Jehovah's Witness Patients to Kidney Transplantation? Transplantation 2021; 105:249-254. [PMID: 33350627 DOI: 10.1097/tp.0000000000003227] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Jehovah's Witnesses (JWs) refuse blood transfusions due to religious issues. This situation may impact kidney transplantation (KT) outcomes in case of hemorrhagic complications. We evaluated demographic characteristics of this population, hematologic safety, and graft outcomes. METHODS This was a retrospective, single-center study comparing KT outcomes in JW patients versus a non-JW control group. Hematologic endpoints included clinical indication for blood transfusion (hemoglobin <7 g/dL), decrease of hemoglobin >2 g/dL or hematocrit >5% in the first week after KT, hemorrhagic complications requiring surgery, and de novo prescription of erythropoiesis-stimulating agents. Secondary endpoints included delayed graft function, treated biopsy-proven acute rejection, renal function, mortality, and graft survival at 12 months. RESULTS From January 1989 to September 2018, we identified 143 JW (10 pediatric) and selected 142 matched control (non-JW) patients. There were no differences in the incidence of clinical indication for transfusion (13.3% versus 11.3%, P = 0.640), but a higher proportion of non-JW patients received transfusions (2.1% versus 9.2%, P = 0.010). There were no differences in the proportion of patients with decreased hemoglobin concentration, in reinterventions due to hemorrhagic complications, in the use of erythropoiesis-stimulating agents at hospital discharge, in the incidence of acute rejection, in renal function, and in mortality or graft survival rate at 12 months. CONCLUSIONS In summary, this matched control cohort study suggests that, when clinically indicated, blood transfusions can be safely avoided in the majority of JW kidney transplant, who achieve and maintain comparable hemoglobin concentrations during the first year after transplantation compared with non-JW patients.
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Affiliation(s)
| | - Klaus Nunes Ficher
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Julia Bernardi Taddeo
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Kamilla Linhares Silva
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Cláudia Rosso Felipe
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Wilson Aguiar
- Urology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Jose Daniel Braz Cardone
- Anesthesiology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Renato Demarchi Foresto
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Hélio Tedesco-Silva
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - José Medina-Pestana
- Nephrology Department, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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17
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Pereira MEVDC, Gonzalez DE, Roberto FB, Foresto RD, Kirsztajn GM, Durão MDS. Listeria monocytogenes meningoencephalitis in a patient with Systemic Lupus Erythematosus. J Bras Nefrol 2020; 42:375-379. [PMID: 32406475 PMCID: PMC7657045 DOI: 10.1590/2175-8239-jbn-2019-0212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/08/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Infectious complications are common in systemic lupus erythematosus. Although uncommon, central nervous system infections do occur and have significant lethality, with several etiological agents. METHODS We report on the case of a 29-year-old woman recently diagnosed with systemic lupus erythematosus with hematological, cutaneous, serous and renal manifestations (class IV lupus nephritis), who underwent corticosteroid pulse therapy and mycophenolate induction therapy. After 3 months of evolution, she developed headache and altered mental status. Computed tomography showed an area of hypoattenuation in the left frontal white matter and her cerebrospinal fluid examination showed pleocytosis and hyperproteinorrhachia. Peripheral blood and CSF culture identified Listeria monocytogenes. The patient presented deterioration of her neurological status, requiring invasive mechanical ventilation, monitoring of intracranial pressure and, despite all the intensive support, persisted in a comatose state and developed multiple organ failure, evolving to death due to nosocomial bloodstream infection. DISCUSSION Infection from L. monocytogenes usually occurs after eating contaminated food, manifesting itself with diarrhea and, occasionally, invasively, such as neurolisteriosis. Further investigation with CSF analysis and MRI is necessary, and the diagnosis consists of isolating the bacteria in sterile body fluid. CONCLUSION The case presents a patient whose diagnosis of meningoencephalitis became an important differential with neuropsychiatric disorder. The poor outcome reinforces the need to remember this infectious condition as a serious complication in the natural history of SLE.
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Affiliation(s)
| | - Diego Ennes Gonzalez
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, Brasil
| | - Fernanda Badiani Roberto
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, Brasil
| | - Renato Demarchi Foresto
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, Brasil
| | - Gianna Mastroianni Kirsztajn
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, Brasil
| | - Marcelino de Souza Durão
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, Brasil
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18
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Foresto RD, Santos DWDCL, Hazin MAA, Leyton ATZ, Tenório NC, Viana LA, Cristelli MP, Silva Júnior HT, Pestana JOM. Chikungunya in a kidney transplant recipient: a case report. ACTA ACUST UNITED AC 2020; 41:575-579. [PMID: 31419273 PMCID: PMC6979562 DOI: 10.1590/2175-8239-jbn-2018-0196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 05/27/2019] [Indexed: 12/14/2022]
Abstract
In 2004, a global spread of Chikungunya fever affected most tropical and subtropical regions of the world. In 2016, an outbreak occurred in Northeast Brazil with hundreds of cases documented. Solid organ transplant recipients have a modified immune response to infection and the clinical course is usually different from immunocompetent patients. The diagnosis can be challenging in this population. Most reports describe patients residing in endemic areas, although we must emphasize the importance of differential diagnosis in kidney transplanted travelers who visit endemic regions, such as Northeast Brazil. Here, we reported a case of a kidney transplant recipient that acquired Chikungunya fever after a trip to an endemic region at Northeast Brazil during the outbreak in 2016, with a good clinical evolution. We also present warning recommendations for travelers to endemic areas as additional measures to prevent disease outbreaks.
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Affiliation(s)
- Renato Demarchi Foresto
- Universidade Federal de São Paulo, Escola Paulista de Medicina São Paulo, SP, Brasil.,Hospital do Rim, Divisão de Nefrologia, São Paulo, SP, Brasil
| | | | - Maria Amélia Aguiar Hazin
- Universidade Federal de São Paulo, Escola Paulista de Medicina São Paulo, SP, Brasil.,Hospital do Rim, Divisão de Nefrologia, São Paulo, SP, Brasil
| | - Alejandro Túlio Zapata Leyton
- Universidade Federal de São Paulo, Escola Paulista de Medicina São Paulo, SP, Brasil.,Hospital do Rim, Divisão de Nefrologia, São Paulo, SP, Brasil
| | | | | | | | - Hélio Tedesco Silva Júnior
- Universidade Federal de São Paulo, Escola Paulista de Medicina São Paulo, SP, Brasil.,Hospital do Rim, Divisão de Nefrologia, São Paulo, SP, Brasil
| | - José Osmar Medina Pestana
- Universidade Federal de São Paulo, Escola Paulista de Medicina São Paulo, SP, Brasil.,Hospital do Rim, Divisão de Nefrologia, São Paulo, SP, Brasil
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Abstract
The scenario of infection by the human immunodeficiency virus (HIV) has been undergoing changes in recent years, both in relation to the understanding of HIV infection and regarding the treatments available. As a result, the disease, which before was associated with high morbidity and mortality, is now seen as a chronic disease that can be controlled, regarding both transmission and symptoms. However, even when the virus replication is well controlled, the infected patient remains at high risk of developing renal involvement, either by acute kidney injury not associated with HIV, nephrotoxicity due to antiretroviral drugs, chronic diseases associated with increased survival, or glomerular disease associated to HIV. This review will cover the main aspects of kidney failure associated with HIV.
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Affiliation(s)
- Érica Lofrano Reghine
- Departamento de Medicina (Nefrologia) da Universidade Federal de São Paulo, São Paulo, SP, Brasil
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20
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Abstract
Acute kidney injury is a very common diagnosis, present in up to 60% of critical patients, and its third main cause is drug toxicity. Nephrotoxicity can be defined as any renal injury caused directly or indirectly by medications, with acute renal failure, tubulopathies, and glomerulopathies as common clinical presentations. Some examples of drugs commonly associated with the acute reduction of glomerular filtration rate are anti-inflammatories, antibiotics, such as vancomycin and aminoglycosides, and chemotherapeutic agents, such as cisplatin and methotrexate. Cases of tubulopathy are very common with amphotericin B, polymyxins, and tenofovir, and cases of glomerulopathies are common with VEGF inhibitors, bisphosphonates, and immunotherapy, and it is also common to have more than one clinical presentation related to a single agent. Early diagnosis is essential for the good evolution of the patient, with a reduction of renal exposure to the toxic agent, which requires knowing the risk factors and biomarkers. General measures such as correcting hydroelectrolytic disorders and hypovolemia, monitoring the serum level, avoiding combinations with the synergy of renal injury, and looking for similar options that are less toxic are the foundations for the treatment of complications that are still common and often preventable.
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Abstract
Type 2 diabetes mellitus is an important public health problem, with a significant impact on cardiovascular morbidity and mortality and an important risk factor for chronic kidney disease. Various hypoglycemic therapies have proved to be beneficial to clinical outcomes, while others have failed to provide an improvement in cardiovascular and renal failure, only reducing blood glucose levels. Recently, sodium-glucose cotransporter-2 (SGLT2) inhibitors, represented by the empagliflozin, dapagliflozin, and canagliflozin, have been showing satisfactory and strong results in several clinical trials, especially regarding the reduction of cardiovascular mortality, reduction of hospitalization due to heart failure, reduction of albuminuria, and long-term maintenance of the glomerular filtration rate. The benefit from SGLT2 inhibitors stems from its main mechanism of action, which occurs in the proximal tubule of the nephron, causing glycosuria, and a consequent increase in natriuresis. This leads to increased sodium intake by the juxtaglomerular apparatus, activating the tubule glomerular-feedback and, finally, reducing intraglomerular hypertension, a frequent physiopathological condition in kidney disease caused by diabetes. In addition, this class of medication presents an appropriate safety profile, and its most frequently reported complication is an increase in the incidence of genital infections. Thus, these hypoglycemic agents gained space in practical recommendations for the management of type 2 diabetes mellitus and should be part of the initial therapeutic approach to provide, in addition to glycemic control, cardiovascular outcomes, and the renoprotection in the long term.
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Affiliation(s)
- Diego Ennes Gonzalez
- Hospital do Rim, Fundação Oswaldo Ramos, Escola Paulista de Medicina, São Paulo, SP, Brasil
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23
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Foresto RD, Uenishi LT, Pestana RC, Neves RFDCA, Aguiar WF, Tedesco Silva H, Pestana JM. Budd-Chiari Syndrome after Bilateral Nephrectomy for Polycystic Kidney Disease in a Kidney Transplant Recipient. Urol Int 2020; 104:330-332. [PMID: 31896110 DOI: 10.1159/000504514] [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: 10/01/2019] [Accepted: 10/28/2019] [Indexed: 11/19/2022]
Abstract
We report a rare case of Budd-Chiari syndrome (BCS) as a postoperative complication after bilateral nephrectomy in a kidney transplant recipient with polycystic liver and kidneys. Contrast-enhanced computed tomography of the abdomen showed a narrowed inferior vena cava, compressed by the polycystic liver that moved downwards after nephrectomy. A stenting angioplasty was performed, resulting in remarkable clinical improvement. This case highlights the need for careful evaluation of polycystic kidneys and their anatomic relationship with the liver before nephrectomy, as well as for considering BCS as a differential diagnosis in similar cases.
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Affiliation(s)
- Renato Demarchi Foresto
- Division of Nephrology, Hospital do Rim, Federal University of São Paulo, São Paulo, Brazil,
| | | | | | | | - Wilson Ferreira Aguiar
- Division of Urology, Hospital do Rim, Federal University of São Paulo, São Paulo, Brazil
| | - Hélio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Federal University of São Paulo, São Paulo, Brazil
| | - José Medina Pestana
- Division of Nephrology, Hospital do Rim, Federal University of São Paulo, São Paulo, Brazil
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25
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Foresto RD, Santos DWCL, Leytón ATZ, Hazin MAA, Viana LA, Silva‐Junior HT, Medina‐Pestana JO. PERFIL DOS TRANSPLANTADOS RENAIS COM INFECÇÃO OU DOENÇA POR CITOMEGALOVÍRUS TRATADOS COM FOSCARNET E ANÁLISE DOS DESFECHOS APÓS A CONVERSÃO DE IMUNOSSUPRESSÃO PARA INIBIDOR DE MTOR. Braz J Infect Dis 2018. [DOI: 10.1016/j.bjid.2018.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Panicio MI, Foresto RD, Mateus L, Monzillo PH, Alves MB, Silva GS. Pneumococcal meningitis, cerebral venous thrombosis, and cervical arterial dissection: a run of bad luck? Neurohospitalist 2013; 3:20-3. [PMID: 23983884 DOI: 10.1177/1941874412459332] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pneumococcal meningitis in adults is widely associated with intracranial complications, which occur in up to 74.7% of the patients. METHOD Case report. RESULTS We report the case of a 40-year-old white female with pneumococcal meningitis after a sinus surgery, who developed a concomitant cerebral venous thrombosis and multiple cervical artery dissections. Following treatment with antibiotics and intravenous heparin, she had complete neurological recovery. CONCLUSIONS Vascular complications should always be remembered and adequately treated in patients with bacterial meningitis. Cervical arterial dissections should be investigated as potential embolic sources of intracranial ischemic lesions.
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Affiliation(s)
- Mauricio Isaac Panicio
- Department of Neurology and Neurosurgery, Federal University of São Paulo-UNIFESP, SP, Brazil
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