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- Early Rehospitalization Post-Kidney Transplant Due to Infectious Complications: Can We Predict the Patients at Risk?Publication . Leal, R; Pinto, H; Galvão, A; Rodrigues, L; Santos, L; Romãozinho, C; Macário, F; Alves, R; Campos, M; Mota, A; Figueiredo, AINTRODUCTION: Rehospitalization early post-kidney transplant is common and has a negative impact in morbidity, graft survival, and health costs. Infection is one the most common causes, and identifying the risk factors for early readmission due to infectious complications may guide a preventive program and improve outcome. The aim of this study was to evaluate the incidence, characterize the population, and identify the risk factors associated with early readmission for infectious complications post-kidney transplantation. METHODS: We performed a retrospective cohort study of all the kidney transplants performed during 2015. The primary outcome was readmission in the first 3 months post-transplant due to infectious causes defined by clinical and laboratory parameters. RESULTS: We evaluated 141 kidney transplants; 71% of subjects were men, with an overall mean age of 50.8 ± 15.4 years. Prior to transplant, 98% of the patients were dialysis dependent and 2% underwent pre-emptive living donor kidney transplant. The global readmission rate was 49%, of which 65% were for infectious complications. The most frequent infection was urinary tract infection (n = 28, 62%) and the most common agent detected by blood and urine cultures was Klebsiella pneumonia (n = 18, 40%). The risk factors significantly associated with readmission were higher body mass index (P = .03), diabetes mellitus (P = .02), older donor (P = .007), and longer cold ischemia time (P = .04). There were 3 graft losses, but none due to infectious complications. CONCLUSION: There was a high incidence of early rehospitalization due to infectious complications, especially urinary tract infections to nosocomial agents. The risk factors identified were similar to other series.
- Fibrogenesis in Kidney Transplant: Dysfunction Progress BiomarkersPublication . Costa, J S; Alves, R; Sousa, V; Marinho, C; Romãozinho, C; Santos, L; Macário, F; Pratas, J; Prado E Castro, L; Campos, M; Figueiredo, AFibrogenesis markers, such as alpha-actin (AA), CD163 (macrophages), and E-cadherin, have been studied as chronic kidney allograft injury (CAI) predictors, a major cause of allograft failure. OBJECTIVE: Investigate the value of these markers in predicting CAI and initiation of dialysis. MATERIALS AND METHODS: Retrospective analysis of 26 kidney allograft biopsies (from 22 patients with CAI) during 2 years, evaluating intensity and percentage of marked cells on glomeruli and tubulointerstitial compartment. At the time of the biopsy, patients were 45.5 ± 15.8 years and 4.2 years after transplant, and they had a mean glomerular filtration rate (GFR) of 25.8 ± 9.9 mL/min. From an average of 8.5 glomeruli per biopsy, there was ≤25% sclerosis in 17 cases, 26% to 50% in 5, and >50% in 4. Interstitial fibrosis or tubular atrophy affected ≤25% of cortical area in 14 cases, 26% to 50% in 8, and >50% in 2. Twelve patients started dialysis 5.8 ± 4.7 years after transplant, with an average GFR 20.9 mL/min at the time of the biopsy. RESULTS: There was a higher intensity and percentage of CD163-marked cells in the tubulointerstitial compartment in advanced interstitial fibrosis. We found an association between intensity of AA in the tubulointerstitial compartment and initiation of dialysis (P = .003) and a negative correlation between intensity of E-cadherin loss and GFR (r = -0.56, P = .012). CONCLUSIONS: In our study, intensity of tubulointerstitial AA was shown to be a predictor of initiation of dialysis, and E-cadherin loss intensity was associated to CAI progression. However, prospective and larger studies are needed to evaluate the predictive value of these markers.
- Nephrotic Range Proteinuria in Renal Transplantation: Clinical and Histologic Correlates in a 10-year Retrospective StudyPublication . Leal, R; Pinto, H; Galvão, A; Santos, L; Romãozinho, C; Macário, F; Alves, R; Pratas, J; Sousa, V; Marinho, C; Prado E Castro, L; Campos, M; Mota, A; Figueiredo, AINTRODUCTION: There is a high incidence of nephrotic proteinuria in renal transplant recipients, which is an accurate predictor of graft loss. Despite this, its histologic correlates and prognostic implications are still not well characterized. We assessed the clinical and histological correlates of kidney transplantation patients with nephrotic range proteinuria. METHODS: We have retrospectively analyzed clinical and histological data from 50 kidney transplantation biopsy specimens from 44 renal transplant recipients with nephrotic range proteinuria between 2006 and 2015. The median follow-up time was 93 months (range, 14 months to 190 months). RESULTS: The mean age of the patients was 45.2 ± 13.7 years and our cohort included 86% recipients of deceased-donor grafts. The maintenance immunosuppressive regimen included calcineurin inhibitors in 68% and mammalian target of rapamycin inhibitors in 32% of patients. The average proteinuria was 6.9 ± 3.8 g/d and 52% of patients presented with nephrotic syndrome. The main histological findings were transplant glomerulopathy (22%), de novo glomerular disease (22%), and recurrence of primary disease (22%). Tubular atrophy and interstitial fibrosis was present in 78% of the biopsy specimens. Thirty-one patients (62%) lost the graft at follow-up. There was no statistically significant difference between the histologic diagnosis nor the proteinuria levels and the outcome of the graft. CONCLUSIONS: The main causes of nephrotic range proteinuria in patients undergoing biopsy were transplant glomerulopathy, recurrence of the underlying disease, and de novo glomerulonephritis. Nephrotic range proteinuria was related to a high rate of graft loss.
- Polyomavirus Nephropathy: Ten-Year ExperiencePublication . Costa, JS; Ferreira, E; Leal, R; Bota, N; Romãozinho, C; Sousa, V; Marinho, C; Santos, L; Macário, F; Alves, R; Pratas, J; Campos, M; Figueiredo, ABACKGROUND: Polyomavirus nephropathy (BKVN) is an important cause of chronic allograft dysfunction (CAD). Recipient determinants (male sex, white race, and older age), deceased donation, high-dose immunosuppression, diabetes, delayed graft function (DGF), cytomegalovirus infection, and acute rejection (AR) are risk factors. Reducing immunosuppression is the best strategy in BKVN. The objective of our study was to evaluate CAD progression after therapeutic strategies in BKVN and risk factors for graft loss (GL). METHODS: Retrospective analysis of 23 biopsies, from patients with CAD and histological evidence of BKVN, conducted over a period of 10 years. Glomerular filtration rate was <30 mL/min in 16 patients at the time of the BKVN diagnosis. RESULTS: BKVN was histologically diagnosed in 23 recipients (19 men, 4 women). All patients were white, with age of 51.2 ± 12.1 years (6 patients, age >60 years), and 22 had a deceased donor. Diabetes affected 4 patients, DGF occurred in 3, cytomegalovirus infection in 2, and AR in 15. All patients were medicated with calcineurin inhibitors (CNI) (95.7% tacrolimus) and corticoids, and 16 also received an antimetabolite. One year after antimetabolite reduction/discontinuation and/or CNI reduction/switching and/or antiviral agents, graft function was decreased in 11 patients, increased/stabilized in 10, and unknown in 2. GL occurred in 9 patients. Older age (hazard ratio, 1.76; 95% confidence interval, 0.94-3.28) and DGF (hazard ratio, 2.60; 95% confidence interval, 0.54-12.64) were the main risk factors for GL. The lower GFR at the time of the BKVN diagnosis was associated with an increased risk of initiation of dialysis. CONCLUSIONS: GL occurred in 39.1% of patients with BKVN and DGF; older age and lower GFR at the time of diagnosis were important risk factors. Early diagnosis of BKVN is essential to prevent GL.
- Surgical Complications in Early Post-transplant Kidney RecipientsPublication . Pinto, H; Leal, R; Rodrigues, L; Santos, L; Romãozinho, C; Macário, F; Alves, R; Bastos, C; Roseiro, A; Costa, F; Campos, M; Mota, A; Figueiredo, ABACKGROUND: The purpose of this study was to determine the incidence of early surgical complications of kidney transplantation in our institution and its association with donor and recipient factors, as well as patient and transplant outcome. METHODS: A retrospective cohort study of all kidney transplants performed during 2015 was made. We evaluated the incidence of surgical complications and the outcome of patients and grafts at a 3-month follow-up interval. RESULTS: During the study period, 141 kidney transplants occurred. Seventeen patients had surgical complications (6 urologic, 6 vascular, and 5 other complications). Five patients lost the graft during the follow-up. Older age was associated with other surgical complications (P = .023), and graft loss was associated with the existence of surgical complications, namely, vascular complications (P <.001). For both surgical complications in general and urologic complications, a statistically significant relationship was found with patient weight (P = .003 and P = .034, respectively). The correlation between body mass index (BMI) and surgical complications was not statistically significant. CONCLUSIONS: Our study reveals that older and heavier patients have a higher risk of surgical complications and that vascular complications are associated with graft loss. A statistically significant relationship was not found between BMI and surgical complications, which could indicate that BMI is not the ideal obesity marker. The incidence of surgical complications found in our study is similar to the literature. The selection of transplant recipients is a difficult task, and the possibility of additional surgical complications in older and overweight patients should be taken into account.
- What Can We Do When All Collapses? Fatal Outcome of Collapsing Glomerulopathy and Systemic Lupus Erythematosus With Diffuse Alveolar Hemorrhage: Case ReportPublication . Pinto, H; Leal, R; Rodrigues, L; Santos, L; Romãozinho, C; Macário, F; Alves, R; Pratas, J; Sousa, V; Marinho, C; Prado E Castro, L; Costa, F; Campos, M; Mota, A; Figueiredo, ANTRODUCTION: Collapsing glomerulopathy (CG) is a rare form of glomerular injury. Although commonly associated with human immunodeficiency virus (HIV) infection, it can occur in association with systemic lupus erythematosus (SLE). CASE REPORT: We present the case of a 50-year-old man, with chronic kidney disease secondary to focal and segmental glomerulosclerosis, who received a cadaveric kidney transplant in 2007. There were no relevant intercurrences until May 2015, when he presented with nephrotic range proteinuria (± 4 g/d). A graft biopsy was performed and it did not show any significant pathological changes. In September, he developed a full nephrotic syndrome (proteinuria 19 g/d) and a graft biopsy was repeated. CG features were evident with a rich immunofluorescence. Antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies were positive; the remaining immunologic study was normal. Viral markers for HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) were negative. The patient was treated with corticosteroid pulses and plasmapheresis (seven treatments). A rapid deterioration of kidney function was seen and he became dialysis dependent. He was discharged with a low-dose immunosuppressive treatment. In October, he was hospitalized with diffuse alveolar hemorrhage (DAH). The auto-immune study was repeated, revealing complement consumption and positive titers of ANA and Anti-dsDNA antibodies. Anti-neutrophil cytoplasmic antibodies (ANCAs) and antiglomerular basement membrane antibody (anti-GBM) were negative. Treatment with intravenous corticosteroids, plasmapheresis, and human immunoglobulin was ineffective and the outcome was fatal. CONCLUSION: This case report highlights the possible association of CG and SLE. To our knowledge, it is the first case of SLE presenting with CG and DAH, with the singularity of occurring in a kidney transplant recipient receiving immunosuppression.
- Síndrome hipertensiva hiponatrémica em destaque – um caso clínicoPublication . Ferreira, DM; Tavares-da-Silva, E; Clemente, H; Leitão, S; Aragão, A; Carvalho, ADescrita pela primeira vez em 1952, a síndrome hipertensiva hiponatrémica (SHH) é a combinação de hipertensão severa, hiponatremia e isquémia renal. Mais do que rara, a síndrome é principalmente subdiagnosticada. Isto limita o conhecimento real e completo da sua fisiopatologia e jus_fica a inexistência de estudos aleatorizados prospe_vos com avaliação real de opções terapêu_cas. A necessidade de aumentar a consciencialização para a síndrome por parte da comunidade médica é premente, especialmente se _vermos em consideração que é uma síndrome potencialmente curável e com taxas de mortalidade que chegam aos 25% nos adultos. Assim, apresenta-se um caso de SHH, com necessidade de nefrectomia para controlo e tratamento definitivo da síndrome.
- Ureteropieloplastia Laparoscópica: A nossa nova abordagem padrãoPublication . Dinis, P; Nunes, P; Castelo, D; Tavares da Silva, E; Figueiredo, A; Mota, AIntrodução e Objetivos: Síndrome da JUP (SJUP) causa hidronefrose e deterioração da função renal se não corrigido em tempo útil. A ureteropieloplastia (UPP) laparoscópica assumiu relevância na resolução desta patologia. O objetivo do trabalho é apresentar a nossa experiência de UPPs em doentes com SJUP. Material e Métodos: Estudo retrospetivo com análise de dados de 49 doentes com SJUP submetidos a UPP entre 2005 e 2012 no nosso Serviço. Os doentes apresentaram diagnóstico clínico ou funcional de obstrução da JUP. Foram analisadas as características demográficas, clínica, achados funcionais e imagiológicos, duração da cirurgia, tempo de internamento e evolução. O estudo estatístico foi realizado com SPSS, versão 18 e os testes usados foram o t-Student e o Chi-Square. Resultados: Foram submetidas a UPP entre 2005 e 2012, 49 doentes com SJUP. A idade média dos 26 homens e 23 mulheres incluídos foi de 42±18 anos. A queixa mais frequente foi a lombalgia (77,6%), e 8,2% dos doentes eram assintomáticos. Todos os doentes incluídos realizaram estudo ecográfico e funcional com cintigrama renal que comprovava obstrução (83,7%) ou que apresentava padrão de eliminação lenta com clínica associada (16,3%). Verificou-se a presença de vaso acessório em 24% dos doentes com SJUP à esquerda e em 33,3% daqueles com SJUP à direita. As técnicas cirúrgicas utilizadas foram a UPP desmembrada tipo Anderson-Hynes (AH) e a não desmembrada tipo Fenger (F). Contabilizaram-se 10 UPP por via aberta (20,4%), de entre as quais 1 F e 9 AH, e 39 por via laparoscópica (79,6%), 31 AH e 8 F. A duração média das cirurgias abertas foi de 106min (70-135min) e a das laparoscópicas de 129min (45-220min), não sendo esta diferença significativa. Em 2 casos de cirurgia laparoscópica verificaram--se complicações com fístula urinária obrigando a nova intervenção. Uma cirurgia aberta complicou com infecção da ferida operatória. Houve necessidade de conversão numa das 39 cirurgias laparoscópicas (2,6%). O tempo de internamento na cirurgia aberta foi de 6 dias, enquanto que na laparoscópica foi de 3 (p=0,007). O tempo médio de seguimento foi de 12 meses (4-48 meses). A evolução favorável, definida como melhoria ou cura dos sintomas e ausência de obstrução no cintigrama renal de controlo, verificou-se em 91,8% dos doentes. A taxa de sucesso da cirurgia laparoscópica foi de 87,2%, com 71,4% a melhorarem a TFG, e a da aberta de 90%, com 83% de evoluções positivas na TFG. A taxa de sucesso das 40 UPP desmembradas foi de 92,5%, e das 9 UPP não-desmembradas de 88,9%. Conclusão: A UPP laparoscópica é eficaz e segura no tratamento do SJUP, sem tempo cirúrgico significativamente superior, com duração de internamento inferior e taxas de melhoria clínica e de benefício na função renal semelhantes. A pieloplastia laparoscópica é o tratamento padrão para esta patologia.
- Colangiocarcinoma Intra-HepáticoPublication . Castro e Sousa, F; Tavares da Silva, E; Tralhão, JG; Costa, B; Martins, M; Serôdio, M; Martins, RIntrodução: o colangiocarcinoma intra-hepático (CCIhp) é um tumor maligno raro, normalmente diagnosticado num estadio avançado. São objectivos deste estudo avaliar os resultados da terapêutica do CCIhp e os factores prognósticos com significado estatístico na sobrevida de doentes com esta entidade nosológica tratados no nosso Serviço. Material e métodos: Vinte e um doentes submetidos a tratamento por CCIhp nos últimos anos, dos quais onze foram operados com intuitos curativos: quatro hepatectomias esquerdas, duas hepatectomias esquerdas alargadas aos segmentos V e VIII, duas hepatectomias direitas, duas bissegmentectomias e uma trissegmentectomia. Resultados: a mortalidade per-operatória foi de 0% e a pós-operatória (três meses) de 6%. As sobrevidas cumulativas aos 5 anos foram de 14% no total da população, 26% nos doentes submetidos a cirurgia com intuitos curativos e 26% para a sobrevida cumulativa livre de doença. Observou-se recidiva tumoral hepática em cinco doentes, a qual ocorreu aos 1,09 ± 0,82 anos (limites: 0,24-2,08). Os factores que influenciaram a sobrevida da globalidade dos doentes foram o tratamento cirúrgico com intuitos curativos (p=0,028), a presença de invasão vascular (p=0,002) e o valor da fosfatase alcalina no momento do diagnóstico (p=0,044). Entre os doentes operados com intuitos curativos, a presença de invasão vascular influenciou a sobrevida global (p=0,025) e a sobrevida livre de doença (p=0,002). Conclusões: A ressecção cirúrgica com intuitos curativos aumentou, de forma estatisticamente significativa, a sobrevida dos doentes com CCIhp. No entanto, sendo o diagnóstico geralmente tardio, apenas uma pequena percentagem destes doentes pode beneficiar deste tratamento.
- Pretransplant biopsy in expanded criteria donors: do we really need it?Publication . Tavares da Silva, E; Oliveira, R; Castelo, D; Marques, V; Sousa, V; Moreira, P; Simões, P; Bastos, C; Figueiredo, A; Mota, AAbstract INTRODUCTION: Renal transplantation is the best treatment for end-stage renal disease, including when using expanded criteria donors (ECD) kidneys. However, these suboptimal kidneys should be evaluated rigorously to meet their usefulness. Opinions differ about the best way to evaluate them. MATERIALS AND METHODS: We retrospectively reviewed kidneys from ECD harvested by a single academic institution between January 2008 and September 2013. Needle biopsies were performed at the time of the harvest when considered relevant by the transplant team. Two pathologists where responsible for their analysis; the Remuzzi classification has been used in all cases. RESULTS: We evaluated 560 ECD kidneys. Biopsies were made in 197 (35.2%) organs, 20 of which were considered not usable and 36 good only for double transplantation. Sixty-three kidneys (11.3%) were discarded by the transplant team based on the biopsy result and clinical criteria. Donors who underwent a biopsy were older (P < .001) and had a worse glomerular filtration rate (GFR; P = .001). Comparing donors approved and rejected by the biopsy, the rejected donors were heavier (P = .003) and had a lower GFR (P = .002). Cold ischemia time was longer for the biopsy group (P < .001). Regarding graft function, the biopsy overall score correlated with the transplant outcome in the short and long term. Separately, glomeruli and interstitium scores were correlated with recipient's GFR in the earlier periods (3 months; P = .025 and .037), and the arteries and tubules correlated with GFR in the longer term (at 3 years P = .004 and .010). CONCLUSION: The decision on the usability of ECD grafts is complex. At our center, we chose a mixed approach based on donor risk. Low-risk ECD do not require biopsy. In more complex situations, especially older donors or those with a lower GFR, prompted a pretransplant biopsy. The biopsy results proved to be useful as they relate to subsequent transplant outcomes, thereby allowing us to exclude grafts whose function would most probably be less than optimal.